Patient's Personal Information

First Name:
MI:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Phone number (mobile preferred):
Email:

If patient is a minor, give parent's or guardian's name:
How did you hear about our practice?




Responsible Party Information

First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Birthdate:
Address:
City:
State:
Zip:
Email:
Phone number (mobile preferred):

Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Birthdate:
Phone number (mobile preferred):

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
Policy Holder’s Date of Birth (XX/XX/XXXX):
Insurance Company:
Subscriber ID #:
Policy Holder’s Social Security Number:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Do you have dual dental coverage?
(If yes, complete information below)

Policy Holder's Name:
Relationship to Patient:
Policy Holder’s Date of Birth (XX/XX/XXXX):
Insurance Company:
Subscriber ID #:
Policy Holder’s Social Security Number:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:

Emergency Information

Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:

Patient Dental History

Does the patient have a dentist that they see on a regular basis?
If Yes, please enter their name:
Check-up Frequency:
Last Dental Visit:
Does the Patient need to premedicate prior to dental visit?

Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Speech problems/therapy?
Oral habits (thumb/finger sucking, lip/nail biting)?
Injury to face, jaw, teeth or mouth?
Chipped or injured permanent teeth?
Previous periodontal (gum) treatment?
Abnormal swallowing (tongue thrust)?
Brush teeth daily?
Floss teeth daily?
Fluoride treatments?
Mouth breathing?
Snores during sleep?
Any missing or extra permanent teeth?
Apprehensive about dental care?
Jaw Fractures, cysts, mouth infections?
Bleeding gums?
Other periodontal (gum) problems?
Additional dental work needed?
If any of the above dental questions were answered 'Yes', please explain:
Do you have a history of jaw joint problems?
Have you been treated for "TMJ"?
Do you notice clicking or popping in your jaw joint?
Do you clench your teeth?
Has your jaw ever locked?
Do you have difficulty chewing or opening your mouth?
Do you experience soreness in the muscles of your face or around your ears?
If any of the above TMJ questions were answered 'Yes', please explain:

Reason for Seeking Orthodontic Evaluation

What is the patient’s main orthodontic concern? i.e. What would the patient like to fix about his/her smile?
Has the patient had previous orthodontic treatment?
If so, when and where?
Has the patient had or is scheduled for another orthodontic consultation?
If so, with whom and when?
What treatment option are you most interested in hearing about during your consultation?


What treatment modality would you like to use to improve your smile? Check all that apply.
If orthodontic treatment is recommended, finances for treatment will be discussed during your appointment. We offer various payment options to our patients and can customize the structure of your financial contract to best suit your needs. Please let us know what is most important to you:

Are you moving out of the area within the next 6 months?

Patient Medical History

Physician Name:
Date of Last Physical:
Patient Health:
Address:
City:
State:
Zip:

Has there been any change in the patient's general health within the last year?
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?
Are you taking any medications (including non-prescription)?
If Yes, please list below.
Allergies or drug reaction to:
Latex
Penicillin or other antibiotics
Sulfa drugs
Aspirin, Ibuprofen, Tylenol
Local anesthetics
Codeine or other narcotics
Metal Allergy
Any additional drug allergies or sensitivities not listed above?
If Yes, please list below.
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Heart Murmur
Damaged or artificial heart valves
Congenital Heart Defect
Heart Disease
Rheumatic Fever
Angina
Liver Disease / Jaundice / Hepatitis
Kidney Disease
Heart Attack/Stroke
Hemophilia
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia / Blood disorder
HIV/AIDS
Tonsils/Adenoids Removed
Handicaps/Disabilities
Arthritis / Joint problems
Large Tonsils
Sinus trouble
Bed wetting
Substance abuse problem (past or present)
Bone fractures/trauma to face/jaw
Prosthetic joints
Chronic fatigue
Diabetes
Growth Problems
Tuberculosis or Lung Disease
Pneumonia
Cancer
Family History of Cancer
Received Radiation Treatment
Arteriosclerosis
Thyroid / Endocrine Problems
Stomach ulcer or hyperacidity
Hormone Therapy
Nervous Disorders
Bone Disorders/Bone Loss
Seizures / Epilepsy / Neurological Disease
Treated for Emotional Problems
Asthma
Respiratory problems / Emphysema
Persistent swollen neck glands
Sexually transmitted disease
Low blood pressure
Persistent cough
FEMALES: Are you pregnant
Take Bisphosphonates (Fosamax, Boniva)
If any of the above medical questions were answered 'Yes' , please explain:

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Height:
Weight:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has his voice changed or has he gotten facial hair?
Has the patient grown in the past year or has his/her shoe size changed recently?
PLEASE REVIEW AND MAKE SURE ALL QUESTIONS WITH A RED ASTERISK ‘*’ HAVE BEEN ANSWERED BEFORE CLICKING "SUBMIT". FORM WILL NOT SUCCESSFULLY SUBMIT IF ALL QUESTIONS WITH A RED ASTERISK ARE NOT FILLED OUT.