Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Non-binary
Address:
City:
State:
Zip:
Home Phone:
Social Security #:
If patient is a minor, please provide name(s) of parent(s)/guardian(s):
Whom may we thank for referring you to our office?
School:
Grade:
Please list names, dates of birth, and ages of children/siblings:
Please list some hobbies or interests:
Responsible Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Residence:
City:
State:
Zip:
Mailing Address:
City:
State:
Zip:
How long at this address?
Home Phone:
Cell/Other Phone:
Email Address:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Work Phone:
Spouse or Other Parent/Guardian First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Work Phone:
Dental Insurance Information
Insured's Name:
Date of Birth:
Social Security #:
Policy Holder's Employer:
Policy Group Number:
Insurance Company Name:
Insurance Company Phone:
Do you have dual dental coverage?
No
Yes
(If yes, complete the following)
Insured's Name:
Date of Birth:
Social Security #:
Policy Holder's Employer:
Policy Group Number:
Insurance Company Name:
Insurance Company Phone:
Emergency Information
Emergency Contact (nearest you):
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Address:
Phone:
Medical History
Physician Name:
Phone:
Date of Last Visit:
Address:
City:
State:
Zip:
Are you in good health?
Yes
No
Do you have a history of a major illness?
Yes
No
Have you had any operations or been hospitalized?
Yes
No
Have you ever been involved in a serious accident?
Yes
No
Have you ever smoked or chewed tobacco?
Yes
No
Please list any medications currently being taken by the patient (include over-the-counter):
Allergies or drug reaction to:
Aspirin, Ibuprofen, or Tylenol?
Yes
No
Latex?
Yes
No
Metal?
Yes
No
Please list any other drug allergies or sensitivities that the patient may have:
Have any tonsils or adenoids been removed?
Yes
No
Female patients only:
Are you pregnant?
Yes
No
Are you nursing?
Yes
No
Children only:
Has patient reached puberty?
Yes
No
If patient is a girl, has menstruation begun?
Yes
No
If patient is a boy, has their voice changed?
Yes
No
If any of the above medical questions were answered 'Yes' , please explain:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Abnormal Bleeding/Hemophilia
Yes
No
Anemia
Yes
No
Arthritis
Yes
No
Asthma
Yes
No
Bone Disorders
Yes
No
Bronchitis
Yes
No
Cancer
Yes
No
Congenital Heart Defect
Yes
No
Diabetes
Yes
No
Developmental Disorder
Yes
No
Dizziness
Yes
No
Endocrine Disorder
Yes
No
Epilepsy/Convulsions/Seizures
Yes
No
Glaucoma
Yes
No
Growth Disorder
Yes
No
Kidney Disease
Yes
No
Hay Fever/Allergies
Yes
No
Heart Attack/Stroke
Yes
No
Heart Murmur
Yes
No
Heart Problems
Yes
No
Hepatitis/Jaundice
Yes
No
Herpes/Cold Sores
Yes
No
High/Low Blood Pressure
Yes
No
HIV+/AIDS?
Yes
No
Leukemia
Yes
No
Liver Disease
Yes
No
Lung/Respiratory Problems
Yes
No
Migraines/Severe Headaches
Yes
No
Nervous Disorders
Yes
No
Pneumonia
Yes
No
Prolonged Bleeding
Yes
No
Psychiatric Problems
Yes
No
Radiation/Chemotherapy
Yes
No
Rheumatic/Scarlet Fever
Yes
No
Sexually Transmitted Disease
Yes
No
Sinus Problems
Yes
No
Stomach Trouble/Ulcers
Yes
No
Thyroid Problems
Yes
No
Tuberculosis
Yes
No
Are there any other medical conditions we have not discussed that you feel we should be aware of?
Dental History
General Dentist:
Phone:
Date of most recent dental exam/cleaning/x-rays (please be sure to insert the
Month
and
Year
):
What are the main concerns you would like Orthodontics to address?
Have you ever had or been evaluated for Orthodontic treatment?
Yes
No
Are you presently in any dental pain?
Yes
No
Have you ever experienced any unfavorable reaction to denstistry?
Yes
No
Have you ever lost or chipped any teeth?
Yes
No
Have you ever been informed of any missing or extra teeth?
Yes
No
Have there been any injuries to face, mouth, or teeth?
Yes
No
Is any part of your mouth sensitive to temperature?
Yes
No
Is any part of your mouth sensitive to pressure?
Yes
No
Do your gums bleed when you brush?
Yes
No
Are you aware of your jaw joint clicking or popping (TMJ/TMD)?
Yes
No
Are you aware of clenching/grinding of your teeth?
Yes
No
Do you have "tension" headaches?
Yes
No
Have you ever experienced chronic ringing in your ears?
Yes
No
Do you have any type of thumb or tongue habit?
Yes
No
Do you have any speech problems?
Yes
No
Are you a mouth breather?
Yes
No
Has anyone in your family received orthodontic treatment?
Yes
No
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
Yes
No
Are you aware that some appointments will be during school/work hours?
Yes
No
If patient under 18:
Mom's Height:
Dad's Height:
If any of the above dental questions were answered 'Yes', please explain:
I understand that I am responsible for payment of services rendered and also responsible for paying any co-payments and deductibles that my insurance does not cover. In the event of a default on agreed upon payment arrangements, I am responsible for reasonable collection costs. I have truthfully answered all of the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Bita Orthodontic Group to perform a complete orthodontic evaluation.
I understand the
Bita Orthodontic Group Parent Office Policy
.
I have read and agree to the
Bita Orthodontic Group Appointment Policy
.
I have received access to the
Bita Orthodontic Group HIPAA Notice of Privacy Practices
. This notice is also available on request at the office.
I give consent to release of images as described in the
Bita Orthodontic Group Social Media and Photo Release Policy
.
Should I need to request a copy of the x-rays taken after the exam appointment for myself or my child, there will be a $95.00 charge.
Patient (Parent/Guardian if minor) E-Signature: