Patient Information
*Legal First Name:
MI:
*Last Name:
Nickname:
*Main Phone:
*Birthdate:
Age:
*Gender:
Male
Female
*Address:
*City:
*State:
*Zip:
If patient is a minor, give parent's or guardian's name:
School:
What are the names and ages of siblings in household:
*Whom may we thank for referring you to our office?
Responsible Party Information
*First Name:
Middle Initial:
*Last Name:
Marital Status:
Select
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
*Birthdate:
Same as patient
Physical Address:
City:
State:
Zip:
Mailing address is the same as physical
*Mailing Address:
*City:
*State:
*Zip:
How long at this address?
Previous Address (less than 3 years)
Primary Email:
Secondary Email:
*Main Phone:
2nd/Cell Phone:
Work Phone #:
Social Security #:
Employer:
Occupation:
Years Employed:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Social Security #:
Birthdate:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Employer:
Occupation:
Length of Employment:
*Main Phone:
2nd/Cell Phone:
Work Phone #:
How would you like to receive appointment reminders?
Phone
Text
Email
I prefer not to receive reminders
Insurance Information
Subscriber's Name:
Policy Holder's Employer:
Birthdate:
Insurance Company:
Primary Insurance ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Subscriber's Name:
Policy Holder's Employer:
Birthdate:
Insurance Company:
Secondary Insurance ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Dental History
Dentist:
Physician:
Oral Surgeon:
Date of last dental examination?
Is dental work complete?
Yes
No
How often do you brush your teeth?
How often do you floss?
Have you ever had an injury to your face or jaw?
Yes
No
Are you aware of tooth grinding or clenching habits?
Yes
No
Do you have speech problems?
Yes
No
Do you breathe mostly through your mouth?
Yes
No
Does orthodontic/dental treatment make you anxious?
Yes
No
Does your jaw make a "clicking" or "popping" sound when you chew?
Yes
No
Medical History
Are you in good health?
Yes
No
Are you currently under the care of a physician?
Yes
No
If so, what is the condidition being treated?
Have you ever had any serious illnesses or operation?
Yes
No
If so, please list:
Are you taking any drugs or medication?
Yes
No
If so, please list:
Are you sensitive or allergic to any drugs?
Yes
No
If so, please list:
For minors, has the patient reached puberty?
Yes
No
Menstruated at age:
Voice changed at age:
Height:
Weight:
Do you have a tendency to colds, sore throats, or ear infections?
Yes
No
Have you had your tonsils or adenoids removed?
Yes
No
Have you ever been exposed to or tested positive for HIV?
Yes
No
Do you smoke or use tobacco?
Yes
No
Do you have, or have you had any of the following? (check all that apply)
Anemia
Blood Diseases
Rheumatism or Arthritis
Heart Ailments
Hepatitis, Jaundice or Liver Disease
Head Injuries
High Blood Pressure
Kidney Disease
Stomach Ulcers
Respiratory Problems
Tumors or Growths
Difficulty in Swallowing
Tuberculosis
Radiation treatment of any kind
Venereal Disease
Nervous Disorders
Allergies
Acquired Immune Difficiency
Diabetes
Asthma or Hay Fever
Epilepsy
Excessive Bleeding
Fainting Spells or Seizures
Mental Disorders
Rheumatic Fever
Artificial Prosthesis
Stroke
Glaucoma
Herpes
Sinus Trouble
Please list any conditions not covered above:
Emergency Information
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
The above information is true to the best of my knowledge. I understand that where appropriate, credit bureau reports may be obtained. I authorize my insurance benefits be paid directly to Valley Orthodontics. I understand that I am financially responsible for any balance. I also authorize Valley Orthodontics or insurance company to release any information required to process my claims.