First Name:
MI:
Last Name:
Preferred Name:
Gender:
Date of Birth:
Home Phone:
Address:
City:
State:
Zip:
Current General Dentist:
How long since the last dental visit?

How did you hear about our office?
Have we treated a family member or friend?
If yes, Name(s):
Name of individual filling out this form:
Is this your first visit to an orthodontist?
What are the main concerns that you would like orthodontics to correct?
Is there anything that you would like to discuss with Drs. Littlefield or Lovell in private?
First Name:
Last Name:
Marital Status:
Relationship to Patient:
Address:
City:
State:
Zip:
Email:
Main Phone:
2nd/Cell Phone:
Work Phone #:
Employer:
Occupation:

Other Parent's First Name:
Last Name:
Relationship to Patient:
Employer:
Occupation:
Cell Phone #:
If you have an insurance card we would be happy to make a copy and enter this information for you at your visit.
Insured's Name:
Insured's Employer:
Insured's Social Security #:
Insured's Date of Birth:
Insurance Company:
Insurance Company Phone:
Insurance Company Address:
Group #:
Policy #:
Do you have secondary coverage?

Insured's Name:
Insured's Employer:
Insured's Social Security #:
Insured's Date of Birth:
Insurance Company:
Insurance Company Phone:
Insurance Company Address:
Group #:
Policy #:
Child's Physician:
Date of Last Physical:
Is the child currently undergoing any medical treatment?
If yes, for what reason?
History of major illness?
If yes, please describe:
History of trauma or injury to the face or teeth?
If yes, please describe:
Any sensitivities or allergies (Latex, Antibiotics, etc.)?
If yes, please list:
Currently taking any medications?
If yes, please list:

Has the child been treated for any of the following?

Does this child require antibiotics prior to dental treatment?
Have the adenoids or tonsils been removed?
Has the child ever had pain or tenderness in the jaw joint (TMJ)?

Does/did the child have any of the following habits?

By checking the boxes and signing below, I am giving my consent to Littlefield & Lovell Orthodontics regarding the following:

Signature:
Date: