Your answers are for office records only and are confidential.

Patient Information

Age:
Patient's First Name:
Middle Initial:
Last Name:
Preferred Name:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Social Security #:
Main Phone:
Home Phone:
Email:
How did you hear about our office?
Has anyone in your family or someone you know been treated in this office? If so, please name them.
Office location perference:

Financial Party Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Marital Status:
Relationship to Patient:
Social Security #:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Work Phone:
Email:
Employer:
Occupation:
Secondary Financal Party
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Social Security #:
Address (if different):
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Work Phone:
Email:
Employer:
Occupation:

Dental Insurance Information

Do you have insurance that covers orthodontics?
(If so, please continue )
Primary Policy Holder's Full Name:
Birth Date:
Social Security #:
Employer:
Relationship to Patient:
Address and phone (if not listed above):
Insurance Company Name:
Insurance Company Phone:
Member ID:
Group Number:
Do you have secondary dental/orthodontic coverage?
(If so, please continue)
Secondary Policy Holder's Full Name:
Birth Date:
Social Security #:
Employer:
Relationship to Patient:
Address and phone (if not listed above):
Insurance Company Name:
Insurance Company Phone:
Member ID:
Group Number:

Dental History

Checkup Frequency:
Last Dental Visit:
Dentist Name:
Address:
Has the patient had an orthodontic consult or treatment? If so, when?
What is the patient's main orthodontic concern?
Any dental pains or problems needing attention?
If yes, please describe:
Please select 'YES' if the patient has had any of the conditions listed below either now or in the past.
Speech problems or therapy?
Clench or grind teeth?
Discomfort from teeth or gums?
Frequently chew gum?
Thumb, finger, lip or pacifier sucking?
Finger or nail biting?
Missing or extra permanent teeth?
Dental treatment (Crown, Bridge, Implant, etc)?
Brush teeth daily?
Floss teeth daily?
Fluoride treatments?
Mouth breathing?
Snores during sleep?
Abnormal swallowing (tongue thrust)?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Your answers are for office records only and are confidential. A thorough medical history is essential to complete orthodontic evaluation.
Physician Name:
Date of Last Physical:
Patient Health:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past.
Birth defects or hereditary problems
Bone fractures or major injuries?
Injury to face, head, neck?
Arthritis or joint problems?
Endocrine or thyroid problems?
Diabetes or low blood sugar?
Kidney problems?
Cancer, tumor, radiation or chemotherapy?
Stomach ulcer or acid reflux?
Immune system problems?
Osteoporosis?
Sexually transmitted disease?
AIDS or HIV positive?
Hepatitis, jaundice, other liver problems?
Polio, Mono, TB, or Pneumonia?
Seizures, fainting spells, neurologic problem?
Depression?
Vision, hearing, or speech problems?
Anorexia, bulimia?
High or low blood pressure?
Bruise easily, anemia?
Chest pain, shortness of breath, tire easily?
Heart defect, murmur, heart attack?
Stroke?
Skin disorder (other than acne)?
Frequent headaches or migraines?
Frequent ear infections, colds, throat infections?
Asthma, sinus problems, hay fever?
Tonsils or adenoid condition?
Latex (gloves, balloons) sensitivity?
Local anesthetics (lidocaine, novocaine) sensitivity?
Require pre-medication prior to any dental treatments?
Currently have (or ever had) a substance abuse problem?
Chew or smoke tobacco (including vaping/e-cigarettes)?
Handicaps or disabilities?
Take bisphosphonates or medication for bone density?
List any other allergies or drug sensitivies that the patient may have:
List any other medications currently being taken by the patient:
If any of the above medical questions were answered 'Yes' , please explain:
Are there any other health problems not listed? Please describe.
If patient is woman: Are you pregnant?
Are you considering pregnancy during the next 2 years?

TMJ (Jaw Joint) History

Have you experience any issues with your “TMJ” jaw joints or jaw muscles?
If yes, have you ever been treated?
If so, when?
By whom?
Was the problem the same or different than your current problem?
Pain, tenderness, or noise in either jaw?
Do you have difficulty opening/closing your mouth?
What would you like your treatment here to achieve?

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Please list the name and birthdate of any siblings:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Has patient begun puberty?
If patient is a girl, has menstruation begun?
If patient is a boy, has their voice changed or have facial hair?
Has the patient grown in the past year or has their shoe size changed recently?
Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment?

Photo Release

Please download and review the full Photo Release Authorization form here.
AAC Orthodontics may occasionally use patient images or treatment progress photos for educational or promotional purposes (including social media and digital platforms). We value your privacy and will not share any images without your permission.
Signature:
Date:

Consent for Use and Disclosure of Health Information (HIPAA)

Please download a copy and review the Notice of Privacy Practices (HIPAA) PDF

I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights regarding the use and disclosure of my protected health information. This information may be used for purposes such as coordinating my treatment, obtaining payment from third-party payers, and supporting healthcare operations like quality reviews.

I acknowledge that I have received and reviewed the Notice of Privacy Practices provided by AAC Orthodontics, which outlines these uses and my rights in more detail, including the right to request restrictions on how my information is used or disclosed. While AAC Orthodontics is not required to agree to the requested restrictions, it must comply with any it does accept. I also understand that I may revoke my Consent at any time by providing written notice to the contact listed above. I acknowledge that this revocation will not affect any actions taken prior to its receipt and may result in AAC Orthodontics being unable to continue my care.

I understand that the information I have provided is accurate to the best of my knowledge, and I will notify AAC Orthodontics of any changes in my or my child’s medical or dental health. I authorize the dental staff to perform any necessary services, and I acknowledge that it is my responsibility to keep the office informed of any updates. I also understand that by completing this form, I will not hold the orthodontist or their staff responsible for any errors or omissions on my part.

By typing my name below, I agree that this is my electronic signature.
Signature of Patient/Guardian:
Date:
If this Consent is signed by a personal representative on behalf of the patient, please complete the following:
Name of Personal Representative:
Relationship to Patient:
You are entitled to a copy of this consent after you sign it.