Confidential Patient Information

* First Name:
MI:
* Last Name:
Nickname:
* Birthdate:
* Gender:
* Address:
* City:
* State:
* Zip:
* Phone Type:
* Phone:
Phone Type:
Phone:
* Email:
Social Security #:

If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
* How did you hear about our practice? (Dentist, Friend, Sign, Internet - List any that apply)

Financial Party Information

* First Name:
Middle Initial:
* Last Name:
Marital Status:
Relationship to Patient:
* Birthdate:
* Address:
* City:
* State:
* Zip:
How long at this address?
Previous Address (less than 3 years)
* Phone Type:
* Phone:
Phone Type:
Phone:
Email:
Social Security #:
Employer:
Occupation:
Length of Employment:

Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Social Security #:
Birthdate:
Employer:
Occupation:
Length of Employment:
Work Phone #:

Dental Insurance Information

Do you have dental coverage?
(IF YES, REQUIRED FIELDS AS NOTED BELOW)
* Policy Holder's Name:
* Policy Holder's DOB:
* 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:
* Policy Holder's DOB:
* Relationship to Patient:
Policy Holder's Employer:
* Insurance Company:
* Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:

Dental History

* Dentist Name:
Check-up 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?
 Does the patient brush daily?
 Does the patient floss daily?
What is the patient's main orthodontic concern?

Please check any of the following that apply:
If any of the above conditions were selected, please explain:
If any of the above conditions were selected, please explain:

Medical History

Physician Name:
Date of Last Physical:
Patient Health:

* 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/hospitalization in the past 5 years? If so, what for?
List any medications currently being taken by the patient (include non-prescription):
List any drug allergies or sensitivities that the patient may have:
Does the patient have any of the following conditions? Check all that apply.
If any of the above conditions were selected, please explain:

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Height:
Weight:
School:
Grade:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Has either biological parent ever had orthodontic treatment: