Patient Information

First Name:
Middle Initial:
Last Name:
Prefers to be called:
Birthdate:  
Age:
Gender:
Has any immediate member of your family been a patient in our office?
If so, Name/Relationship:
Whom may we thank for referring you to our practice?
List any hobbies, interests, or musical instruments played:
Is Patient Adopted?
Any special concerns about undergoing orthodontic treatment?

Dental History

Dentist Name:
Check-up Frequency:
Last Dental Visit:
Location:
Has the patient had an orthodontic consultant or treatment?
If so, when?
Brush teeth daily?
Floss teeth daily?
Speech problems/therapy?
Grind or clench teeth?
Oral habits (thumb/finger sucking, lip/nail biting)?
Until what age?
Mouth breathing?
Snores during sleep?
Any missing or extra permanent teeth?
Apprehensive about dental procedures?
Frequently chew gum?
Teeth sensitive to hot/cold?
Frequent canker/cold sores?
Biological parent had orthodontic treatment?
Fluoride treatments?
Injury to face, jaw, teeth or mouth?
Discomfort from teeth or gums?
Pain, tenderness or noise in either jaw?
Frequent headaches?
Neck/shoulder pain?
Frequent sore throats?
Difficulty chewing/swallowing food?
Teeth throb/ache?
Would the patient mind wearing braces?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Location:
List any serious illnesses or medical problems:
Has the patient ever taken bisphosphonate drugs (Fosamax, Boniva, Actonel)?
List any allergies (including latex, vinyl, metals, drugs/medications):
List any prescription and non-prescription drugs now being taken:
Has the patient had any of the conditions listed below. Please select YES or NO. Do not leave blank.
Diabetes
Pneumonia
Heart Trouble
Rheumatic Fever
Tuberculosis
Mononucleosis
Mental Retardation
Autism
Arthritis
Epilepsy
Asthma
Anemia
Prolonged Bleeding
Bone Disorders
Frequent colds/flu
Learning Disabilities
ADD/ADHD
Physical Disabilities
HIV
Ear Infections
Emotional Problems
Thyroid Problems
Fainting/Dizzy Spells
Adenoids Removed
Tonsils Removed
Hepatitis
Growth Problems
Pregnant?
Due Date:  
If any of the above medical questions were answered 'Yes' , please explain:

For Patients Under 18

School:
Grade:
Names and Birthdates of Siblings:
Has patient begun puberty:
If patient is female, has menstruation begun:
If patient is male, has his voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Does the patient's facial appearance most resemble:

Treatment Information

I grant permission for the following people to receive Treatment information regarding my / my child's treatment.

Name and Relationship to Patient:
E-Signature:
Date:

Financial Information

Who is financially responsible for this account?
Relationship:
Physical Address:
City:
State:
Zip:
Mailing Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Work Phone #:
Email:
Employer:
Occupation:
# of years there?
Spouse:
Spouse Employer:
Spouse Occupation:
# of years there?

Financial Information

I grant permission for the following people to receive financial/treatment information on my or my child's account: (list names & relationship)
Name and Relationship to Patient:
E-Signature:
Date:

Custodial Parent Information

Is Custodial Parent/Guardian the same as person listed above?

If no, please provide the following information:

Custodial Parent/Guardian Name:
Physical Address:
*City:
*State:
*Zip:
Mailing Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Work Phone #:
Email:

Relationship Information

Father

Name:
Address:
Home Phone:
Cell Phone:
Occupation:
Employer:

Mother

Name:
Address:
Home Phone:
Cell Phone:
Occupation:
Employer:

Stepfather

Name:
Address:
Home Phone:
Cell Phone:
Occupation:
Employer:

Stepmother

Name:
Address:
Home Phone:
Cell Phone:
Occupation:
Employer:

Insurance Information

Dental/Orthodontic insurance is a benefit purchased by/for you to help cover your treatment fees. We cannot be responsible for the type of policy that has been purchased. As a courtesy, we will complete and file a claim on your behalf; however you are responsible for the entire fee. If the information you supply is incomplete or inaccurate, you will be responsible for full payment to our office as well as filing claims to your insurance carrier.

Primary Insurance

Dental Coverage:
Orthodontic Coverage:
Subscriber Name:
Subscriber Date of Birth:  
Subscriber SSN:
Subscriber Insurance ID #:
Subscriber Group #:
Subscriber Employer:
Insurance Company:
Insurance Address:
Insurance Phone #:
Date insurance became effective:

Secondary Insurance

Dental Coverage:
Orthodontic Coverage:
Subscriber Name:
Subscriber Date of Birth:  
Subscriber SSN:
Subscriber Insurance ID #:
Subscriber Group #:
Subscriber Employer:
Insurance Company:
Insurance Address:
Insurance Phone #:
Date insurance became effective: