Patient Biographical Information
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First Name:
Middle Initial:
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Last Name:
Nickname:
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Birthdate:
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Gender:
Male
Female
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Address:
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City:
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State:
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Zip:
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Main Phone:
2nd/Cell Phone:
Email:
Occupation or School Level:
Please list the names of any family currently in the practice:
List any sports, hobbies, or musical instruments played and other interests:
Whom may we thank for referring you to our practice?
Emergency Contact
Person to be contacted in case of emergency:
Relationship:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Phone Number(s):
Responsible Party Information
Check if the patient is also the person who will be financially responsible for treatment.
Responsible Party 1
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First Name:
Middle Initial:
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Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Email:
*
Address:
*
City:
*
State:
*
Zip:
*
Main Phone:
2nd/Cell Phone:
Employer:
Occupation:
Work Phone #:
Responsible Party 2
First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Email:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Employer:
Occupation:
Work Phone #:
Dental Insurance Information
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Subscriber Date of Birth:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Do you have dual dental coverage?
Yes
No
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Subscriber Date of Birth:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Medical History
Physician Name:
Office Phone:
Date of Last Exam:
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Are you currently under medical treatment?
Yes
No
If so, please explain for what:
List any medications currently being taken by the patient (include non-prescription):
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Taken/Taking Bisphosphonates?
Yes
No
If yes, for what condition
FEMALES: Are you or could you be pregnant?
Yes
No
Allergies or drug reaction to:
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Latex
Yes
No
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Penicillin or other antibiotics
Yes
No
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Sulfa drugs
Yes
No
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Aspirin, Ibuprofen, Tylenol
Yes
No
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Local anesthetics
Yes
No
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Codeine or other narcotics
Yes
No
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Other:
Yes
No
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.
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Hypertension/High Blood Pressure
Yes
No
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Rheumatic Fever
Yes
No
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Heart Murmur
Yes
No
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Mitral Valve Prolapse
Yes
No
*
Heart Conditions
Yes
No
*
Epilepsy/Convulsions
Yes
No
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Fainting/Seizures
Yes
No
*
Hay Fever/Allergies
Yes
No
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ADHD
Yes
No
*
Tuberculosis
Yes
No
*
Thyroid Problems
Yes
No
*
Kidney Disease
Yes
No
*
Respiratory Problems
Yes
No
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Diabetes
Yes
No
*
Asthma
Yes
No
*
X-ray/Radiation (Cancer) Therapy
Yes
No
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HIV/AIDS
Yes
No
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Hepatitis/Jaundice
Yes
No
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Any developmental/genetic issues that would effect how we communicate with your child
Yes
No
If any of the above medical questions were answered 'Yes' , please explain:
Dental History
Dentist Name:
Address:
Phone:
Last Dental Visit:
Do you authorize release of information about orthodontic treatment to the patient's dentist?
Yes
No
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
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Bleeding gums?
Yes
No
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Frequent headaches?
Yes
No
*
Teeth sensitive to hot or cold food/liquids?
Yes
No
*
Teeth sensitive to sweet or sour food/liquids?
Yes
No
*
Clench or Grind Teeth?
Yes
No
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Bite Lips or Cheeks?
Yes
No
*
Had Blows to Teeth?
Yes
No
*
Pain in Any Teeth?
Yes
No
*
Any Difficult Extractions?
Yes
No
*
Frequent Sores In/Around Mouth?
Yes
No
*
Prolonged Bleeding After Extractions?
Yes
No
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Head, Neck or Jaw Injuries?
Yes
No
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Clicking in the Jaw?
Yes
No
*
Pain in the Jaw?
Yes
No
*
Difficulty Opening or Closing Jaw?
Yes
No
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Difficulty in Chewing?
Yes
No
*
Have or Had Thumb/Finger Habit?
Yes
No
*
Had Prior Orthodontic Consultation or Treatment?
Yes
No
Please explain the nature of the orthodontic problem in your own terms:
Authorization and Release
I certify that the above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize Dr. Simi to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child for orthodontic care to the patient's general dentist, third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to Dr. Simi, insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
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Completed By:
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Date:
Date Reviewed:
Date Reviewed:
Date Reviewed: