Patient Information

* First Name:
Middle Initial:
* Last Name:
Gender:
* Address:
* City:
* State:
* Zip:
* Home Phone:
* Birthdate:
Email:
Siblings and Ages:
If patient is a minor, give legal guardian's name(s):

Orthodontic Insurance Information

Do you have:
Policy Holder's Name:
Social Security #:
Birthdate:  
Subscriber ID:
Insurance Company Name:
Address:
Insurance Group Number:

Responsible Party Information

* First Name:
Middle Initial:
* Last Name:
Marital Status:
* Residence:
* City:
* State:
* Zip:
How long at this address:
* Home Phone:
Work Phone #:
Birthdate:  
Email (for appointment reminders):
Relationship to Patient:
Previous Address (if less than 3 years):
City:
State:
Zip:
Employer:
Occupation:
No. Years Employed:
Spouse
Last Name:
First Name:
Middle:
Relationship to Patient:
Birthdate:  
Employer:
Occupation:
No. Years Employed:
Work Phone:

Patient Medical History

Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
* Is the patient in good general health at this time?
* Is the patient under the care of a physician at this time?
* Is the patient taking any medication(s)?
* Is the patient allergic to any medications?
* Has patient had tonsils and adenoids removed?
* Has the patient ever had serious injuries or been hospitalized?
* Has the patient ever been advised by a physician to take an antibiotic prior to any dental work?
* Does the patient have any special problems not listed?
Please discuss any items answered yes:

Dental History

Patient's Dentist:
Last Dental Visit:
* Have there been any injuries to the face, mouth, or teeth?
If Yes, please explain:
Has the patient had (past or present) any of the following habits:
* Thumb or finger sucking
* Grinding of teeth at night
* Lip Biting
* Mouth Breathing
* Has an orthodontist been consulted previously for this patient?
* Has there been orthodontic treatment for other family members?
If Yes, treated by Dr.
Has patient ever been treated for:
* TMJ
* "Bad Bite"
* Periodontal Gum Disease
* Does the patient have any speech problems?
* Is the patient concerned or anxious about orthodontic treatment?
Please explain any concerns about the appearance of the teeth and anything you would like to change about the smile:

Has the Patient Ever had any of the Following?

* Congenital Heart Defect
* Heart Disease
* Hearing Impairment
* Heart Murmur
* Rheumatic Fever
* Prosthetic (Artificial) Joint
* Radiation Therapy
* Respiratory/Lung Disease
* High Blood Pressure
* Low Blood Pressure
* Hepatitis
* Tuberculosis
* Aids or H.I.V. Positive
* Venereal Disease
* Herpes (oral cold-sores)
* Blood Disorders
* Jaw Clicking
* Jaw Pain
* Emotional Issues
* Inflammatory Rheumatism
* Arthritis
* Diabetes
* Ulcers
* Stroke
* Anemia
* Asthma
* Epilepsy
* Glaucoma
* Fainting Spells
* Kidney Trouble
* Liver Disease
* Psychiatric Treatment
* Drug Addiction
* Headaches
* Earaches
* Allergies
* Tonsilitis
* Other
PLEASE DISCUSS ANY ITEMS ANSWERED YES:

Bisphosphonates

* Are you currently taking OR have you EVER taken a Bisphosphonate medication, commonly used for Osteoperosis and other conditions that feature bone fragility? Bisphosphonates are sometimes marketed as Boniva, Fosomax, Fosomax+D, Actonel, Reclast, Actonel+Ca, Aredia, Didronel, Skelid, and Zometa.

If yes, when did you begin the medication?
When did you end the medication?

Acknowledgement

Benefits of Orthodontics include aesthetics, health, and function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay, decalcification, and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I understand that my diagnostic records and my name may be used for educational purposes. I also understand that orthodontic appointments are often during work and/or school hours. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. Overby Orthodontics will not be held responsible for any problems arising out of inadequate or undisclosed information. In addition, I authorize Dr. Overby to perform a complete orthodontic evaluation.

Person Completing Form:

COVID-19 Informed Consent

Orthodontic Treatment in the Era of COVID-19


Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as "Coronavirus", at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.
Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant. "Social Distancing" nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, orthodontist, orthodontic staff and sometimes other patients at all times.
* Although exposure is unlikely, do you accept the risk and consent to treatment?
* Patient/Parent/Guardian Signature:
* Date: