Personal Information
First Name:
Middle Initial:
Last Name:
Nickname:
Address:
City:
Zip:
Home Phone:
Birthdate:
Age:
School:
Hobbies & Interests
Gender:
Male
Female
Other
Parent's Information
Father
First Name:
Middle Initial:
Last Name:
Birthdate:
Address:
City:
Zip:
Phone:
Cell Phone:
Email:
Employer:
Occupation:
Employer Address:
City:
Zip:
Work Phone:
Mother
First Name:
Middle Initial:
Last Name:
Birthdate:
Address:
City:
Zip:
Phone:
Cell Phone:
Email:
Employer:
Occupation:
Employer Address:
City:
Zip:
Work 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
Have tonsils and adenoids been removed?
Yes
No
At what age?
List any drugs or medications now being taken. Give reasons:
List any allergies or drug sensitivity:
Dental History
Have there been any injuries to the face, mouth, or teeth?
Yes
No
Has the patient ever sucked a thumb or fingers?
Yes
No
What age?
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
Invisalgin (Clear Aligners)
Retainers
Airway - Apnea Treatment
Tmj Issues
Other
Signature