Confidential Patient Information

* First Name:
* Last Name:
* Birthdate:
* Gender:
* Address:
* City:
* State:
* Zip:
* Main Phone:
2nd/Cell Phone:
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:
Whom may we thank for referring you to our practice?

Financial Party Information

* First Name:
Middle Initial:
* Last Name:
Marital Status:
Relationship to Patient:
* Birthdate:
* Address:
* City:
* State:
* Zip:
* Main Phone:
2nd/Cell Phone:
Social Security #:
Work Phone #:
Length of Employment:

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

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Policy Holder's Date of Birth:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
Insurance Co. Phone No.:
Do you have dual dental coverage?
(If yes, complete information below)

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Policy Holder's Date of Birth:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
Insurance Co. Phone No.:

Emergency Information

Name of nearest relative not living with you:
Complete Address:
Relationship to Patient:

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?
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.
* Speech problems/therapy?
* Clench or Grind Teeth?
* Oral habits (thumb/finger sucking, lip/nail biting)?
* 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?
* Chipped or injured permanent teeth?
* Teeth sensitive to hot or cold?
* Previous root canal therapy?
* Bad taste/mouth odor?
* Previous periodontal (gum) treatment?
* Abnormal swallowing (tongue thrust)?
* Teeth that irritate tongue, cheek, lip, etc?
* Numerous fillings?
* Brush teeth daily?
* Floss teeth daily?
* Fluoride treatments?
* Mouth breathing?
* Snores during sleep?
* Any missing or extra permanent teeth?
* Apprehensive about dental care?
* Frequently Chew Gum?
* Thumb or finger habit as a child?
* Jaw Fractures, cysts, mouth infections?
* Bleeding gums?
* Other periodontal (gum) problems?
* Frequent canker sores or cold sores?
* Have wisdom teeth been removed?
* Problems with food trapped between teeth?
* Is all dental work completed at this time?
If any of the above dental questions were answered 'Yes', please explain:
* Have you had a TMJ screening?
* Do you have a history of jaw joint problems?
* Have you been treated for "TMJ"?
* Do you notice clicking or popping in your jaw joint?
* Do you clench your teeth?
* Has your jaw ever locked?
* Do you have difficulty chewing or opening your mouth?
* Does your bite feel uncomfortable or unusual?
* Do you experience soreness in the muscles of your face or around your ears?
If any of the above TMJ questions were answered 'Yes', 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):
Allergies or drug reaction to:
* Latex
* Penicillin or other antibiotics
* Sulfa drugs
* Aspirin, Ibuprofen, Tylenol
* Local anesthetics
* Codeine or other narcotics
* Other:
List any drug allergies or sensitivities (not listed above) 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.
* Heart Murmur
* Damaged or artificial heart valves
* Congenital Heart Defect
* Heart Disease
* Angina
* Liver Disease / Jaundice / Hepatitis
* Kidney Disease
* Heart Attack/Stroke
* Hemophilia
* Hypertension/High Blood Pressure
* Prolonged Bleeding/Transfusion
* Anemia / Blood disorder
* Tonsils/Adenoids Removed
* Handicaps/Disabilities
* Arthritis / Joint problems
* Large Tonsils
* Sinus trouble
* Anxiety
* Substance abuse problem (past or present)
* Bone fractures/trauma to face/jaw
* Smoking/Vaping Habit
* Chronic fatigue
* Diabetes
* Growth Problems
* Tuberculosis or Lung Disease
* Pneumonia
* Cancer
* Family History of Cancer
* Received Radiation Treatment
* Depression
* Thyroid / Endocrine Problems
* Stomach ulcer or hyperacidity
* Hormone Therapy
* Metal Allergy
* Nervous Disorders
* Bone Disorders/Bone Loss
* Seizures / Epilepsy / Neurological Disease
* Psychiatric Treatment
* Asthma
* Respiratory problems / Emphysema
* Persistent swollen neck glands
* Sexually transmitted disease
* Low blood pressure
* Persistent cough
FEMALES: Are you pregnant
* Take Bisphosphonates (Fosamax, Boniva)
If any of the above medical questions were answered 'Yes' , please explain:

Patient Motivation for Orthodontic Treatment

Patients often request changes in their bites or faces and relief from pain or discomfort. Please help us to understand your concerns by checking the following information; please be specific (check the words - upper, lower, more, etc.)

Teeth - If your teeth could be changed, how would you like them to change?

Patients Under 18

If patient is under the age of 18, please answer the following questions:
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:


Your protected health information (i.e. individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:

  • To other health care providers (i.e., your general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you (i.e., to determine the results of cleanings, surgery, etc.);
  • To third party payers or spouses (i.e., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e., to determine benefits, dates of payment, etc.);
  • To certifying, licensing and accrediting bodies (i.e., the American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation;
  • Internally, to all staff members who have any role in your treatment;
  • To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling, etc.;
  • To your family and close friends involved in your treatment; and/or,
  • We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke.

Under the new privacy rules, you have the right to:

  • Request restrictions on the use and disclosure of your protected health information;
  • Request confidential communication of your protected health information;
  • Inspect and obtain copies of your protected health information through asking us;
  • Amend or modify your protected health information in certain circumstances;
  • Receive an accounting of certain disclosures made by us of your protected health information; and,
  • You may, without risk of retaliation, file a complaint as to any violation by use of your privacy right with us (by submitting inquiries to our Privacy Contact Person at our office address) or the United States Secretary of Health and Human Services (which must be filed within 180 days of the violation).

We have the following duties under the privacy rules:

  • By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information;
  • To abide by the terms of our Privacy Notice that is currently in effect, and,
  • To advise you of our right to change the terms of this Privacy Notice and to make the new notice provisions effective for all protected health information maintained by us, and that if we do so, we will make available to you, a copy of the revised Privacy Notice.

Please note that we are not obligated to:

  • Honor any request by you to restrict the use or disclosure of your protected health information;
  • Amend your protected health information if, for example, it is accurate and complete; or,
  • Provide an atmosphere that is totally free of the possibility that your protected health information may be accidentally overheard by other patients and third parties.

This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Contact Person or direct your questions to this person at our office address. Thank you.