Patient Information

First Name:
MI:
Last Name:
Nickname:
Birthdate:
Sex:
Address:
City:
State:
Zip:
Primary Phone:
Cell Phone:
Email:
Emergency Contact Name:
Emergency Contact Phone:
Relationship to Patient:

Who can we thank for referring you to our office? List name and relationship, if applicable.
Interests and Hobbies:
School:
Names/Ages of Siblings:

Responsible Party Information

Responsible Party/Parent 1
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Address:
City:
State:
Zip:
Primary Phone:
Cell Phone:
Email:
Employer:
Responsible Party/Parent 2
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Employer:
Are Parents:

Dental Insurance

Primary Insurance Policy Holder Name:
Birthdate:
Address:
City:
State:
Zip:
Insurance Co:
Ins. Address:
Group #:
ID #:
Relationship to Patient:
Secondary Insurance Policy Holder Name:
Birthdate:
Address:
City:
State:
Zip:
Insurance Co:
Ins. Address:
Group #:
ID #:
Relationship to Patient:

Dental History

Dentist Name:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when?
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.
Clench or grind teeth?
Discomfort from teeth or gums?
Frequent headaches?
Injury to face, jaw, teeth, or mouth?
Mouth breathing?
Oral habits (thumb or finger sucking, lip or nail biting)?
Pain, tenderness, or noise in either jaw?
Requires premedication?
Speech problems or therapy?
Treated for periodontal disease?
Vomit, gag or faint easily?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
Please list any medications currently being taken by the patient (include non-prescription):
Please list any other drug allergies or sensitivities that the patient may have:
Please list any other allergies that the patient may have:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Abnormal blood pressure?
Arthritis or joint problems?
Asthma?
Bisphosphonates (Fosamax, Boniva)?
Blood disorder?
Bone disorders or loss?
Cancer?
Congenital heart defect?
Current or former tobacco user?
Diabetes?
Heart attack or stroke?
Heart disease?
Heart murmur?
Hepatitis?
HIV or AIDS?
Kidney disease?
Latex or metal allergy?
Rheumatic fever?
Seizures, epilepsy, or neurological disease?
Tonsils or adenoids removed?
Tuberculosis or lung disease?
Other?
If any of the above medical questions were answered 'Yes' , please explain:
Are you aware that some appointments may be made during school or work?
Do we have your consent to communicate with your general dentist?
I have reviewed a copy of the TC Orthodontics Notice of Privacy Practices. Click here to review

I understand that the information that I have given today is correct to the best of my knowledge. I hereby authorize the release of any information pertaining to my dental treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

Signature of Patient (or Guardian if under 18)
Date