Patient Biographical Information

* First Name:
* Last Name:
* Birthdate:
* Gender:
* Address:
* City:
* State:
* Zip:
* Main Phone:
2nd/Cell Phone:
* Email:
Social Security #:
Marital Status:
Spouse's Name:
Emergency Contact:
Emergency Phone:

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?

Patients Under 21

If patient is under the age of 21, please answer the following questions:
Please list the name and birthdate of any siblings:
Father/Guardian 1 Name:
Father/Guardian Address:
Mother/Guardian 2 Name:
Mother/Guardian Address:
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:
Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment:

Financial Party Information

* First Name:
Middle Initial:
* Last Name:
* Birthdate:
Relationship to Patient:
* Email:
* City:
* State:
* Zip:
* Main Phone:
2nd Phone:
Social Security #:
Work Phone:

Do you have insurance that covers orthodontics?
If so, please name the Insurance Company below:
Insurance Co. Phone No.:
Insurance Co. Address:
Insured's Name:
Relationship to Patient:
Insured's SS #:
Insured's Group #.:
Insurance ID:

Dental History

Dentist Name:
Check-up Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
If so, when?
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?
* Injury to face, jaw, teeth or mouth?
* Discomfort from teeth or gums?
* Pain, tenderness or noise in either jaw?
* Frequent headaches?
* Oral habits (thumb/finger sucking, lip/nail biting)?
* Neck/shoulder pain?
* Bleeding gums?
* Brush teeth daily?
* Floss teeth daily?
* Fluoride treatments?
* Mouth breathing?
* Snores during sleep?
* Requires premedication
* Any missing or extra permanent teeth?
* Apprehensive about dental care?
* Frequently Chew Gum?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

List any medications currently being taken by the patient:
List any drug allergies or sensitivites 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.
* Scarlett/Rheumatic Fever
* Tuberculosis/Lung Disease
* Pneumonia
* Kidney/Liver Disease
* Lupus
* Heart Attack/Stroke
* Heart Disease
* Congenital Heart Defect
* Mitral Valve Prolapse/Heart Murmur
* Hemophilia
* Hypertension/High Blood Pressure
* Prolonged Bleeding/Transfusion
* Anemia
* Venerial Disease/HIV/AIDS
* Hepatitis
* Tonsils/Adenoids Removed
* Cancer
* Family History of Cancer
* Received Radiation Treatment
* Growth Problems
* Endocrine Problems
* Hormone Therapy
* Latex/Metal Allergy
* Nervous Disorders
* Artificial Bones/Joints/Valves/Bone Disorders/Bone Loss
* Diabetes
* Seizures/Epilepsy
* Handicaps/Disabilities
* Asthma/Other Respiratory
* Arthritis
* Ulcers/Colitis
* Sinus Problems
* Treated for Emotional Problems
* Operations/Hospitalizations
If any of the above medical questions were answered 'Yes' , please explain:


This form is used to obtain authorization to release Protected Health Information

I understand that I, or my child, have/ has certain rights to privacy regarding my/ his/ her protected health information. These rights are given to me/ him/ her under the Health Insurance Portability and Accountability Act of 1996 (HIPPA). I understand that by signing this consent I authorize Stan D. Drabik, DDS and its employees to use and disclose my protected health information to carry out:

1. Treatment (including treatment by other healthcare providers involved in my treatment).

2. Payment collection from third party payers (i.e. insurance companies).

3. The day to day healthcare operations of the practice.

4. Educational and demonstrational activities.

I understand that Stan D. Drabik, DDS reserves the right to change the terms of this notice from time to time and that I may contact Stan D. Drabik, DDS at any time to obtain a more current copy of this notice. I understand that I have the right to request restrictions on how my or my child’s protected health information is used and disclosed to carry out treatment, payment, health care operations, and educational and demonstrational activities. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

* Type Patient's Name or Guardian if under 18 years of age:
* Date: