Patient Information

First Name:
Middle Initial:
Last Name:
Preferred Name:
Birthday:
Sex:
Best Phone #:
Contact Email:
How do you prefer to receive appointment reminders? (Check all that apply):
Relatives treated at our office:
How did you hear about our office?:

If patient is an ADULT, please fill out this section:
Address:
City:
State:
Zip:
Employed By:
Phone:
Spouse’s Full Name:
Employed by:

If patient is a MINOR, please fill out this section:
School:
Grade:
Father's Name:
Mother's Name:
Parents' Marital Status:
Patient lives with:
Home Address:
City:
State:
Zip:
Father's Employer:
Cell Phone #:
Mother's Employer:
Cell Phone #:

Insurance Information

Is there any dental insurance we can check for you?
Policy Holder Name:
Insurance Company:
Phone #:
Group #:
ID:
Birthday:
Insured Social Security #:
Employer:

Fun facts for kids (and adults)

Favorite app:
Favorite hobby:
Favorite food:
Favorite sport:

Dental History

Dentist Name:
Date of last visit:
What concerns you most about your teeth?
Have you ever lost or chipped any permanent teeth?
Do you have any type of thumb or tongue habit?
Are you a mouth breather?
Have you ever seen an orthodontist?
If yes, who and when?

Medical History

Physician Name:
Date of Last visit:
Please answer Yes or No (If Yes, please explain). Parents/Guardians please respond for minors.
Are you taking any medications?
Details:
Do you have any allergies (including Latex or Nickel)?
Details:
Do you have a history of a major illness/operation?
Details:
Does your physician recommend pre-medicating with antibiotics?
Details:
Female Patients only: Are you pregnant?
Details:
Are there any medical conditions we have not discussed that you feel we should be aware of?
Details:
Check any of the medical conditions below that you have had or currently have:
I have read and understand the above questions. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes to the medical or dental history, I will so inform this practice.
Signature:
Date: