Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Cell Phone:
Email:
Address:
City:
State:
Zip:
If Patient is a minor, please enter parent/guardian information below:
First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
How did you hear about our office?
Dental Insurance Information
Subscriber's Name:
Insurance Company Name:
Subscriber ID:
Group Number:
Subscriber's DOB:
Subscriber's SSN:
Policy Holder's Employer:
Policy Holder's Occupation:
Member services phone number on ID card:
Dentist Information
Dentist Name:
Location of dentist:
Last Dental Visit:
Any current or pending dental work?
Yes
No
If so, what?
Has the patient had any orthodontic treatment before?
Yes
No
If so, when and what?
What is the patient's main orthodontic concern?
Emergency Contact Information
Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Phone: