Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Preferred Name:
Birthdate:
Gender:
Address:
City:
State:
Zip:

What are the names of any friends or family currently in the practice?
What are the patient's interests (i.e. sports, hobbies, or musical instruments)?
Whom may we thank for referring you to our practice?

Financial Party Information

First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Specify 'Other' Relationship:
Birthdate:
Phone Number:
Main Phone Type:
Address:
City:
State:
Zip:
How long at this address?
Previous address (less than 3 years)?
Email:
Social Security Number:
Employer:
Occupation:

Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Specify 'Other' Relationship:
Birthdate:
Social Security Number:
Phone Number:
Main Phone Type:
Employer:
Occupation:

The above parties:

If divorced, which of the above parties is the primary custodial guardian?

If divorced, does the primary guardian give us permission to discuss treatment/financial information with the other party?

Name any other parties the custodial guardian will allow us to share information with:
Name:
Phone Number:
Name:
Phone Number:
Name:
Phone Number:

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:

Do you have dual dental coverage?
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:

Emergency Contact Information

Name:
Address:
Relationship to Patient:
Phone:

Dental History

Dentist Name:
Checkup Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when?
Does the Patient need to premedicate prior to dental visit?
What is the patient's main orthodontic concern?

Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Chipped or injured permanent teeth?
Clench or grind teeth?
Injury to face, jaw, teeth, or mouth?
Jaw fractures, cysts, or mouth infections?
Mouth breathing?
Oral habits (thumb or finger sucking, lip or nail biting)?
Other periodontal (gum) problems?
Pain, tenderness, or noise in either jaw?
Previous periodontal (gum) treatment?
Speech problems or therapy?

Medical History

Physician Name:
Date of Last Physical:
Patient Health:
Address:
City:
State:
Zip:

Has there been any change in the patient's general health within the last year?
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
Has the patient had a serious illness or hospitalization in the past 5 years? If so, what for?
Please list any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Aspirin, Ibuprofen, or Tylenol?
Latex?
Local anesthetics?
Metal?
Other?
Please list any other drug allergies or sensitivities that the patient may have:
Please select ‘Yes’ if the patient has had any of the conditions/medications listed below either now or in the past. Cannot be blank.
Asthma?
Bisphosphonates (Fosamax, Boniva)?
Bone disorders or loss?
Cancer?
Heart attack or stroke?
Heart defect (congenital)?
Heart disease?
Heart valves are damaged or artificial?
Prosthetic joints?
Radiation treatment?
Tonsils or adenoids removed?
Are You Pregnant?

No patients under age 18 will be examined unless accompanied by a parent/legal guardian.

Signature of legal guardian responsible for account (or signed by patient age 18 and older).