Patient Information Form
First Name:
Middle Initial:
Last Name:
Nickname:
Which of the following best describes you?
Male
Female
Other:
Birthdate:
Address:
City:
State:
Zip:
Cell Phone:
Alternate Phone:
Email:
Patient's School/Occupation:
Whom may we thank for referring you?
How would you like to receive your appointment reminders?
Emails
Texts
Both
None
Parent/Guardian If Under 18
Father/Guardian Name:
Email:
Check if address is the same as the child's.
Address:
City:
State:
Zip:
Cell Phone:
Alternate Phone:
Mother's Name:
Email:
Check if address is the same as the child's.
Address:
City:
State:
Zip:
Cell Phone:
Alternate Phone:
Name and age of sibling(s):
Responsible Party
I am responsible for the account.
Person responsible for account:
Relationship to Patient:
Billing Address:
City:
State:
Zip:
Emergency Contact
Full Name:
Relationship to Patient:
Cell Phone:
Alternate Phone:
Dental Insurance
Do you have dental insurance?
Yes
No
Primary Insured's Name:
Date of Birth:
Insurance Co.
ID No.:
Insurance Co. Address:
Phone:
Insured's Employer:
Group No.:
Relationship to Holder:
Secondary Insured's Name:
Date of Birth:
Insurance Co.
ID No.:
Insurance Co. Address:
Phone:
Insured's Employer:
Group No.:
Relationship to Holder:
I hereby authorize release of any information regarding orthodontic treatment to my dental insurance company and the payment of insurance benefits directly to the orthodontist.
Insurance Holder's Signature:
Date:
Medical History
Primary Care Physician's Full Name:
Phone Number:
Have you ever had or currently have any of the following: (Please check all that apply)
Abnormal Bleeding/Hemophilia
Arthritis
Artificial Heart Valve
Asthma
Bone Disorders
Cancer
Congenital Heart Defect
Diabetes
Endocrine/Thyroid Problems
Epilepsy
Fainting/Dizziness
Frequent Headaches
Gastrointestinal Disorders
Heart Murmur
Heart Problems
Hepatitis/Liver Problems
HIV/AIDS
High Blood Pressure
Immune Disorder
Infective Endocarditis
Joint Swelling
Kidney Problems
Osteoporosis
Radiation/Chemotherapy
Speech, Vision, Hearing Impairment
Sinus Problems
Tuberculosis
Other:
I have none of these
Please explain any/all selected items above:
Please check Yes or No (if Yes, please fill in the details):
Are you taking medications?
Yes
No
Plase list:
Do you have allergies?
Yes
No
Please list Drug, Food, Hayfever, Metal etc.:
Have you had past surgeries?
Yes
No
List types with approximate dates:
Have you ever been hospitalized?
Yes
No
Describe:
Have you ever taken / currently taking Bisphosphonates? (Fosamax, Reclast, Actonel, Boniva, Reclast, Aredia etc.)
Yes
No
Describe:
Do any of your medical conditions require you to be premedicated?
Yes
No
Describe:
Are you taking OTC vitamins, supplements or herbs?
Yes
No
Describe:
Are there any medical conditions we have not discussed that you feel we should be aware of?
Yes
No
Describe:
Females only: Is there a possibility you may be pregnant?
Yes
No
Dental History
Dentist's Name:
Date of last dentist visit:
What is your primary orthodontic concern?
Please check Yes or No (If Yes, please fill in the details):
Have you previously consulted an orthodontist?
Yes
No
Describe:
Do you have pain in your mouth?
Yes
No
Describe:
Have you had any injury to your jaw, face, mouth or teeth?
Yes
No
Describe:
Have you lost a permanent tooth?
Yes
No
Describe:
Have you chipped a tooth?
Yes
No
Describe:
Do your gums bleed when you brush your teeth?
Yes
No
Describe:
Have you ever sucked your thumb or finger(s)?
Yes
No
If so, have you stopped this habit? When?
Do you breathe predominantly through your mouth? :
Yes
No
Describe:
Is there a family history of congenitally missing teeth?
Yes
No
Describe:
Have you had tonsils or adenoids removed?
Yes
No
When?
Do you clench or grind your teeth?
Yes
No
Describe:
Do you now have, or have you ever had, pain in your jaw joint or the sides of your face (in and about the ears)?
Yes
No
Describe:
Have you ever had clicking or popping in your jaw joint?
Yes
No
Describe:
Have you ever experienced pain when you open your mouth wide?
Yes
No
Describe:
Do you have a history of speech problems?
Yes
No
Describe:
Have you had a previous bad dental experience?
Yes
No
Describe:
Do you have dental anxiety?
Yes
No
Describe:
Release and Waiver
I have read the above questions and understand them. I will not hold my orthodontist or any member of his or her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my/my child's medical or dental health.
Patient or Parent/Guardian Signature:
Date:
Acknowledging Receipt of Privacy Practices
NOTE: You may refuse to sign this acknowledgement.
Click here to view a copy of the Notice of Privacy Practices.
I have received a copy of this office's Notice of Privacy Practices.
Print Name:
Signature:
Date:
FOR OFFICE USE ONLY:
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:
Individual refused to sign
Communications barriers prohibited obtaining this acknolwedgement
An emergency situation prevented us from obtaining acknowledgement
Other
Please Specify: