Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Social Security #:

If patient is a minor, who is the parent or guardian?
If patient is a minor, who does the patient live with?
School:
Grade:
What are the patient's interests (i.e. sports, hobbies, or musical instruments)?
Whom may we thank for referring you to our practice?

Financial Party Information

First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Birthdate:
Address:
City:
State:
Zip:
How long at this address?
Previous address (less than 3 years)?
Email:
Main Phone:
Cell Phone:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Work Phone:

Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Birthdate:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Work Phone:

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:

Do you have dual dental coverage?
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:

Emergency Contact Information

Name:
Address:
Relationship to Patient:
Phone:

Dental History

Dentist Name:
Checkup Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when?
Is all dental work completed at this time?
Does the Patient need to premedicate prior to dental visit?
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.
Apprehensive about dental care?
Brush teeth daily?
Chipped or injured permanent teeth?
Clench or grind teeth?
Discomfort from teeth or gums?
Floss teeth daily?
Injury to face, jaw, teeth, or mouth?
Missing or extra permanent teeth?
Mouth breathing?
Oral habits (thumb or finger sucking, lip or nail biting)?
Pain, tenderness, or noise in either jaw?
Speech problems or therapy?
Teeth sensitive to hot or cold?

Have you had a TMJ screening?

Medical History

Physician Name:
Date of Last Physical:
Patient Health:
Address:
City:
State:
Zip:

Has there been any change in the patient's general health within the last year?
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
Allergies or drug reaction to:
Latex?
Metal?
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Anemia or blood disorder?
Asthma?
Bisphosphonates (Fosamax, Boniva)?
Bone disorders or loss?
Cancer in family history?
Diabetes?
Growth problems?
Handicaps or disabilities?
Heart attack or stroke?
Heart defect (congenital)?
Heart disease?
Heart murmur?
Hemophilia?
High blood pressure or hypertension?
HIV or AIDS?
Hormone therapy?
Kidney disease?
Liver disease, jaundice, or hepatitis?
Nervous disorders?
Radiation treatment?
Seizures, epilepsy, or neurological disease?
Stomach ulcer or hyperacidity?
Thyroid or endocrine problems?
Tonsils or adenoids removed?
Tuberculosis or lung disease?
FEMALES: Are You Pregnant?