Brett Crell DDS P.C.

Patient Information

First Name:
MI:
Last Name:
Nickname:
Birthdate:
Gender:
Age:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
Emergency Contact Name:
Emergency Contact Phone:
Whom may we thank for referring you to our practice?
Whom is accompanying the patient today?
Who does the patient live with?
Does this person have legal custody?
Marital status of patient's parents:
We need your marital status for financial/insurance purposes.

Person(s) Responsible for Account

Prefix:
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Relationship to Patient:
Email:
Home Phone:
Cell Phone:
Employer:
Work Phone #:
Prefix:
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Relationship to Patient:
Email:
Home Phone:
Cell Phone:
Employer:
Work Phone #:

Dental Insurance Information

Do you have dental insurance?

Patient Dental History

Dentist Name:
Phone:
Address:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
If so, when?
Have you ever had injuries to the face or teeth?
If so, when?
What type of injury?
Do you have a finger/thumb sucking habit?
If yes, have you tried to stop?
How often do you brush?
How often do you floss?
Select Yes to any that apply.
Bad Breath
Bleeding Gums
Blisters On Lips/Mouth
Burning Sensation on Tongue
Cigarette/Pipe/Cigar Smoking
Dry Mouth
Fingernail Biting
Food Collection Between Teeth
Gag Reflex
Grinding Teeth
Gums Swollen or Tender
Jaw Pain/Tiredness (TMJ)
Lip/Cheek Biting
Loose Teeth/Broken Fillings
Mouth Breathing
Mouth Pain During Brushing
Pain Around Ear
Periodontal (gum) Treatment
Sensitivity to Cold
Sensitivity to Heat
Sensitivity to Sweets
Sensitivity When Biting
Sores/Growths in Mouth

Patient Health History

Primary Care Physician:
Physician Phone:
Have you had any serious illnesses or surgeries?
If yes, please describe:
Please list allergies, including dental anesthetics:
Please list any medications you are taking:
Are you taking or have you ever taken medication for bone density?
Is there any other information you feel we should know to help better care for you or your child?
Select Yes to any that apply.
AIDS/HIV
ADD/ADHD
Asperger's/Autism
Anemia
Arthritis/Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Bleeding/Blood Disease
Cancer
Chemotherapy
Congenital Heart Lesions
Cortisone Treatments
Diabetes
Emphysema
Epilepsy
Fainting/Dizziness
Headaches
Heart Murmur
Heart Problems
* Hepatitis
Type:
High Blood Pressure
Kidney Disease
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Nervousness
Pacemaker
Radiation Treatment
Sinus Trouble
Skin Rash
Stroke
Swollen Feet/Ankles
Swollen Neck Glands
Thyroid Problems
Tonsillitis
Vertigo
Authorization

I have completed the above dental/medical histories to the best of my knowledge. I authorize my insurance company to pay the orthodontist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions. I authorize the release of all information necessary to secure payment of benefits. I authorize that I am financially responsible for all charges whether or not paid by insurance. I have received a copy/been advised of the HIPAA Notice of Privacy Practices. I authorize Brett Crell DDS P.C. to perform any necessary dental services that I may need during diagnosis and treatment.

Patient Signature or Parent/Guardian:
Date: