Patient Information
First Name:
Middle Initial:
Last Name:
Preferred Name:
Birthdate:
Gender:
Male
Female
Responsible Party Information
Check if the patient is their own responsible party.
First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Main Phone:
Address:
City:
State:
Zip:
Are there any other Family members that you would like us to evaluate?
Yes
No
Family members previously seen:
Whom may we thank for referring you to our practice?
Medical/Dental History
Primary Dentist:
Please list any medications currently being taken by the patient:
Please check all that apply
Asthma
Jaw Joint Noise
Teeth Grinding
Diabetes
Bone Disorders
Heart Conditions
Epilepsy
Hepatitis
AIDS/HIV
Tonsils/Adenoids Removed
Latex Allergy
Missing/Extra Teeth
Mouth Breathing
Previous Injury to Face/Jaw
Snoring
Have you had any additional consultations for braces?
No
Yes
Any other medical or dental concerns?
I give my permission for x-rays and photos to be taken:
No
Yes
The office may post my photos on Facebook for contests and before & after portfolio:
No
Yes
Patients Under 18
What school do you attend?
What grade are you in?
Are you excited about braces?
No
Yes
List Sports, Hobbies, Music:
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