Patient Demographic Information

First Name:
Middle Initial:
Last Name:
Preferred Name:
Gender Assigned at Birth:
Pronouns:
Birthdate:
Address:
City:
State:
Zip:
Primary Phone:
Email:
How did you hear about our office?
Name of person referring/other details (if applicable):
If the patient is a minor:
Patient lives with:
Parent(s)/Guardian(s) Names(s):
School:
Grade:
Siblings (Name and Age):

Responsible Party Demographic Information

Parents Marital Status:
Parent/Guardian #1:
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Address:
City:
State:
Zip:
Primary Phone:
Email:
Employer:
Occupation:
Parent/Guardian #2:
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Address:
City:
State:
Zip:
Primary Phone:
Email:
Employer:
Occupation:

Dental Insurance Information

Please fill out as completely as possible to assist us in estimating your benefit. If you do not have dental insurance, please enter N/A into the required fields.
Primary Insurance Company Name:
Group/Client Number:
Insurance Company Address:
Insurance Company Phone:
Subscriber Name:
Subscriber DOB
Subscriber ID/SSN:
Secondary Insurance Company Name:
Group/Plan Number:
Insurance Company Address:
Insurance Company Phone:
Subscriber Name:
Subscriber DOB
Subscriber ID/SSN:
Signature:

Dental History

Patient's General Dentist Name (N/A if none):
Date of Last Visit:
What are your main concerns you would like adressed with your orthodontic treatment?
What is your top priority?
What is your treatment preference?
Have you previously had an orthodontic consultation? If so, when?
Has anyone in your family had orthodontic treatment?
Are you satisfied with their results?
Does the patient currently or ever had any of the following habits?
Any history of injury to the mouth/face?
Have you been informed of missing/extra teeth?
Have the patient's tonsils/adenoids been removed?
Any history of jaw joint clicking or pain?
Do your gums bleed?
History of periodontal treatment (deep cleanings)?
Speech problems/speech therapy?
Is the patient apprehensive about dental care?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of Last Visit:
Is the patient in good health currently?
Currently taking medications?
If YES: please describe:
Does the patient have any allergies:
If YES: please explain:
Does the patient require premedication before dental visits?
Has the patient ever taken bisphosphonates or other medications for osteoporosis?
Children Under 18
Is the patient showing signs of increased growth recently?
Has puberty/menstruation begun?
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past.
Heart Problems?
Hypertension?
Stroke?
Bleeding Disorder?
Diabetes?
Asthma?
Respiratory or Sinus Problems
Smoking/Vaping?
Kidney or Liver Disease?
Epilepsy?
Glaucoma?
Thyroid/Endocrine Problem?
Arthritis?
Prosthetic Joint?
Rheumatoid Arthritis?
Osteoporosis?
Tuberculosis?
HIV/AIDS?
Oral Herpes (cold sores)?
Autism Spectrum Disorder?
ADHD?
Anxiety?
Depression?
Mental Health Concerns?
Cancer/Radiation Treatment?
Sleep Apnea?
Is the patient currently pregnant/nursing?
Other condition not listed:

Notice of Privacy Policies

Signature:
Date:

Our Notice of Privacy Policies are available on our website. You may also receive a copy of our Notice of Privacy Practices, including revisions, at any time by contacting our privacy officer:

Telephone: 612-315-1511
Fax: 612-315-1216
Email: info@impactorthoMN.com
4256 Nicollet Ave, Minneapolis MN 55409

I have received a copy of this practice’s Notice of Privacy Practices and have had the full opportunity to read and consider the contents of this Consent form. I understand that by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.
Signature:
Date: