Personal Information
First Name:
Middle Initial:
Last Name:
Address:
City:
Zip:
Home Phone:
Cell Phone:
Birthdate:
Age:
Email:
Employed By:
Occupation:
Business Address:
Bus Phone:
Hobbies & Interests
Spouse's Name:
Birthdate:
Email:
Employed By:
Occupation:
Business Address:
Bus Phone:
Cell Phone:
Whom may we thank for referring you?
Insurance Information
Person Financially Responsible:
Phone:
Do you have dental insurance?
Yes
No
Insurance Company Name:
Insured Social Security #:
Insured Birthdate:
Medical History
Dentist Name:
Physician Name:
Oral Surgeon Name:
Anemia?
Yes
No
Asthma?
Yes
No
Bone disorders?
Yes
No
Diabetes?
Yes
No
Endocrine problems?
Yes
No
Epilepsy?
Yes
No
Fainting / Dizziness?
Yes
No
Glaucoma?
Yes
No
Heart trouble?
Yes
No
Hepatitis?
Yes
No
HIV / AIDS?
Yes
No
Kidney Involvement?
Yes
No
Liver Involvement?
Yes
No
Nervous disorders?
Yes
No
Pneumonia?
Yes
No
Prolonged bleeding or transfusion?
Yes
No
Rheumatic fever?
Yes
No
Tuberculosis?
Yes
No
List any drugs or medications now being taken:
History of allergies or drug sensitivity (specify):
(FEMALES) Pregnancy?
Yes
No
Are you presently taking birth control pills?
Yes
No
Dental History
Have there been any injuries to the face, mouth, or teeth?
Yes
No
Does the patient have any speech problems?
Yes
No
Have you been informed of any missing or extra permanent teeth?
Yes
No
Has an orthodontist been consulted previously?
Yes
No
Has the patient been diagnosed with sleep apnea?
Yes
No
What are you most interested in today?
Braces
Clear Braces
Invisalign (Clear Aligners)
Retainers
Airway - Apnea Treatment
Tmj Issues
Other
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