Confidential Patient Information

* First Name:
Middle Initial:
* Last Name:
Nickname:
* Birthdate:
* Gender:
Preferred Pronoun:
* Address:
* City:
* State:
* Zip:
* Main Phone:
* Email:
Social Security #:
How did you hear about us?



If you answered Family/Friend or Referral from a Professional, please list them here:
List any sports, hobbies, or musical instruments played:
If the patient is under 18 years of age, please list the name and age of any siblings

Financial Party Information

* First Name:
Middle Initial:
* Last Name:
Birthdate:
Relationship to Patient:
Email:
* Address:
* City:
* State:
* Zip:
* Cell Phone:
Social Security #:
Do you have insurance that covers orthodontics?
If so, please name the Insurance Company:
Employer:
Occupation:
Length of Employment:
Work Phone #:

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Do you have dual dental coverage?
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:

Health History

List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select YES or No for the Following Questions - Do Not Leave Blank
* Rheumatic Fever
* Tuberculosis/Lung Disease
* Pneumonia
* Liver Disease
* Kidney Disease
* Heart Attack/Stroke
* Heart Disease
* Congenital Heart Defect
* Heart Murmur
* Hemophilia
* Hypertension/High Blood Pressure
* Prolonged Bleeding/Transfusion
* Anemia
* HIV/AIDS
* Hepatitis
* Tonsils/Adenoids Removed
* Cancer
* Family History of Cancer
* Received Radiation Treatment
* Growth Problems
* Endocrine Problems
* Hormone Therapy
* Latex/Metal Allergy
* Nervous Disorders
* Bone Disorders/Bone Loss
* Diabetes
* Seizures/Epilepsy
* Handicaps/Disabilities
* Asthma
* Arthritis
* Treated for Emotional Problems
* Ever Been Hospitalized
If any of the above medical questions were answered 'Yes' , please explain:
Physician Name:
Date of last Physical:
Patient Health:
Address:
City:
State:
Zip:

Dental History

Please select Yes/No for the following, occurring in the past or present
* Speech problems/therapy?
* Grind or clench teeth?
* Injury to face, jaw, teeth or mouth?
* Discomfort from teeth or gums?
* Pain, tenderness or noise in either jaw?
* Frequent headaches?
* Oral habits (thumb/finger sucking, lip/nail biting)?
* Neck/shoulder pain?
* Frequent sore throats?
* Brush teeth daily?
* Floss teeth daily?
* Fluoride treatments?
* Mouth breathing?
* Snores during sleep?
* Requires premedication?
* Any missing or extra permanent teeth?
* Apprehensive about dental care?
* Frequently Chew Gum?
If any of the above dental questions were answered 'Yes', please explain:

Oral Hygiene

Brushing Frequency per day
Flosing Frequency per day
Flouride Toothpaste
Juice or Sweetened Beverage intake per day
Snacking sessions per day
Dentist Name:
Check-up Frequency:
Last Dental Visit:

Orthodontic History

Has the patient had an orthodontic consult or treatment?
If so, when?
What is the patients main orthodontic concern?

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Height:
Weight:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Has patient begun puberty:
If applicable, has menstruation begun?
If applicable, has there been a change in voice or growth of 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:

Policies and Authorizations

*I received the Photo Policies, and (select one)
 
 
I authorize the following individuals to discuss patient information and make treatment decisions on the patient’s behalf (Name and relationship, e.g., Jane Doe - Grandmother)
List individuals who may bring the patient to the clinic but are NOT permitted to discuss treatment or make decisions. (Name and relationship)

By signing below, I confirm that I am the patient or have the legal authority as the parent, legal guardian, or authorized representative to sign on behalf of the patient. I certify that the information provided is accurate and complete to the best of my knowledge. I acknowledge that my questions have been answered to my satisfaction and understand that providing false information may harm the patient’s health. I agree to notify the dental office of any changes to the patient’s medical or dental history. This authorization remains valid until updated and supersedes all previous versions.

*Signature:
*Date: