About You
*
First Name:
Middle Initial:
*
Last Name:
*
Birthdate is not in correct format (mm/dd/yyyy)
Birthdate:
*
Gender:
Male
Female
Other
Cell Phone:
Other Phone:
Email:
*
Address:
*
City:
*
State:
*
Zip:
Occupation:
Employer:
How did you hear about our office?
Who is your dentist?
Please list other IMMEDIATE family members seen in our office and their relation to you?
Dental Insurance Information
Primary Insurance
Insurance Company Name:
Group/Plan Number:
Insurance Company Phone:
Policy Holder's Name:
*
Social Security #/Member ID:
*
Birthdate is not in correct format (mm/dd/yyyy)
Birthdate:
Secondary Insurance
Insurance Company Name:
Group/Plan Number:
Insurance Company Phone:
Policy Holder's Name:
Social Security #:
*
Birthdate is not in correct format (mm/dd/yyyy)
Birthdate:
Medical Health Information
What is the reason you are seeking an orthodontic evaluation?
Have you seen an orthodontist previously?
Yes
No
Do you have or have had any of the following diseases or conditions?
*
Allergies (medicine or other)?
Yes
No
*
AIDS, HIV Positive?
Yes
No
*
Asthma?
Yes
No
*
Diabetes?
Yes
No
*
Drug or Alcohol Dependency?
Yes
No
*
Excessive Bleeding or Bruising?
Yes
No
*
Fainting Spells, Seizures?
Yes
No
*
Heart Defect, Heart Murmur, Heard Disease?
Yes
No
*
Hepatitis?
Yes
No
*
Herpes, Fever Blisters?
Yes
No
*
High/Low Blood Pressure?
Yes
No
*
Joint Replacement or Implant?
Yes
No
*
Latex Sensitivity or Allergy?
Yes
No
*
Metal or Nickel Sensitivity or Allergy?
Yes
No
*
Scarlet Fever, Rheumatic Heart Disease?
Yes
No
*
Stroke?
Yes
No
*
Tonsils or adenoids removed?
Yes
No
*
FEMALES: Are You Pregnant?
Yes
No
If you responded yes to any question, please explain:
*
Do you now or have you ever taken bisphosphonates, including Fosomax, Didronel, Boniva, Actonel, Skelid, or Zometa?
Yes
No
If yes, which drug?
Do you have any disease, condition, or problem not listed that you think we should know about? Please explain.
Please list any medications currently being taken (include non-prescription):
Signature:
Date: