Confidential Adult Patient Information

* Last Name:
* First Name:
Middle Name:
* Main Phone:
* Mobile Phone:
* Email:
* Address:
* City:
* State:
* Zip:
* Birthdate (MM/DD/YYYY):
Social Security #:
Marital Status:
Work Phone:
Spouse Information
First Name:
Middle Initial:
Last Name:
Spouse's Birthdate (MM/DD/YYYY):
Spouse's Employer:
Spouse's Cell Phone:

* Phone number we should use to confirm appointments:
* Email address we can use for appointment reminders:
* Text number we can use for appointment reminders:
Whom may we thank for referring you to our practice?

Responsible Party Information

Person financially responsible for account:
* Last Name:
* First Name:
Middle Initial:
Social Security #:
* Birthdate (MM/DD/YYYY):
Relationship to Patient:
* Address:
* City:
* State:
* Zip:
Home Phone:
Work Phone #:
* Mobile Phone:
Correspondence should be sent to:

Insurance Information

* Does your dental insurance cover orthodontics?
Email copy of your insurance card to questions@hohlortho.com
Primary Dental Insurance Company & Address:
Subscriber's Name:
Subscriber's Social Security #:
Subscriber's Relationship to Patient:
Subscriber's Address:
Subscriber's Birthdate:
Subscriber's Employer:
Subscriber's ID:
Subscriber's Group #:
Secondary Dental Insurance Company & Address:
Subscriber's Name:
Subscriber's Social Security #:
Relationship to Patient:
Subscriber's Address:
Subscriber's Birthdate:
Subscriber's Employer:
Subscriber's ID:
Subscriber's Group #:

Dental History

What is the main orthodontic problem as you see it?
Are you sensitive about the appearance of your teeth?
Are you sensitive about the appearance of any facial features? (nose, chin, lips, etc.)
What do you consider the main benefits of orthodontic treatment?
How do you feel about wearing braces?
Have you ever had an orthodontic consultation?
Have you ever had braces before?
If yes, when?
Has anyone in the family received orthodontic treatment?
If yes, who?
What would you like orthodontic treatment to accomplish?
Are you interested in:
Name of your general dentist:
Frequency of dental checkups:
Date of last dental exam (MM/YY):

Answer yes or no if applicable now or in the past:
* Apprehensive about dental care
* Jaw joint sounds
* Difficulty chewing or opening
* Brush teeth daily
* Jaw joint pain
* Cysts or mouth infections
* Floss teeth daily
* Jaw "tires" when eating
* Fluoride treatments
* Jaw catches when opening
* Previous orthodontic therapy
* Jaw locks in closed position
* Frequent canker sores
* Jaw locks in open position
* Speech therapy
* Thumb/finger sucking habit
* Jaw pain or ringing in ears
* Frequently chews gum
* Wake up with sore teeth
* Had periodontal treatment
* Gag reflux
* Discomfort from teeth or gums
* Bleeding gums
* Wake up with sore jaw
* Body piercing
* Snores when sleeping
* Oral surgery
* Teeth that are shifting
* Mouth breathing
* Any missing permanent teeth
* Any injuries to face, mouth, teeth
* Sleeps with mouth open
* Injury to teeth
* Grinding of teeth
* Injury to either jaw
* Frequent clenching of teeth
* Other
If you answered yes to any of the above, please explain:

Medical History

Patient's Physician:
Approximate date of exam (MM/DD/YYYY):
Are currently seeing a Physical Therapist or Chiropractor?
If yes, Name & Address:
Are you currently in good physical health?
If no, briefly explain below:
Please list any medications you are currently taking:
List any drug allergies or sensitivities you may have:

Answer yes or no if applicable now or in the past:
* Allergies (latex-gloves/balloons)
* Allergies (metals-jewelry/clothing)
* Allergies (acrylic)
* Allergies (medication)
* Allergies (food)
* Allergies (seasonal)
* Enlarged tonsils
* Tonsils or adenoids removed
* Frequent sore throats
* Cleft palate/lip
* Asthma
* Anemia
* Radiation treatment
* Cancer
* Family history of cancer
* Bone disorder/bone loss
* Immunodeficiency
* Endocrine problems
* Heart murmur
* Heart attack/stroke
* Congenital heart defect
* Hormone therapy
* Diabetes
* Hepatitis
* Rheumatic fever
* Tuberculosis
* Heart disease
* Liver disease
* Kidney disease
* Lung disease
* Pneumonia
* Arthritis
* Emotional problems
* Pyschological counseling
* Handicaps/disabilities
* Requires premedication
* Ever been hospitalized
* Tobacco use
* Bottle-fed
* Breastfed
* Born premature
* Hemophilia
* Are you pregnant? (females)
* Right or left handed
* Facial pain
* Frequent headaches
* Tongue thrust
* Back or neck injuries
* Back, neck or shoulder pain
* Frequent nausea
* Dizziness
* Balance issue
* Scoliosis
* Growth problems
* Ear pressure
* Foot/Ankle sprain
* Knee, hip, foot pain
* Autism
* Nervous disorder/anxiety
* Intermittent blurred vision
* Tone/Ringing in ears
* Torticollis
* Loss of place when reading
* Hypersensitivity (light, sound, movement)
* Difficulty with comprehension or mental fog
* Hypertension/high blood pressure
* Frequent or large changes in vision
* Other
If any of the above medical questions were answered 'Yes' , please explain:

What is Most Important

We recognize that each patient family has individual needs and expectations.

Our Goal is to Meet and Exceed Yours!

Please briefly describe what is most important to you/your family in choosing an orthodontic specialist.

Authorization for Cell Phone and Email Use

I give my consent to the orthodontic practice to use my cell phone for appointments, treatment information, insurance, account and billing information and special promotions. I understand that I can withdraw my consent at any time.

Check all that apply:

Photographic / Media / Social Media Consent

  • Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Hohl Orthodontics and its affiliates and agents, to use my image, video and photographic likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet and Social Media sites).
  • I hereby consent to the collection and use of my personal images by photography or video recording.
  • I further acknowledge that Hohl Orthodontics may use my image in media to promote the practice in the future.
  • I understand that no personal information, such as names, will be used in any publications unless express consent is given.
  • I also understand that my consent can be withdrawn at anytime in writing to Hohl Orthodontics.
* I have read the above statements and I give this consent voluntarily.

HIPAA Consent

This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Consent Person or direct your questions to this person at our office address.

Release of Medical/Dental Information

I hereby give permission to disclose (discuss, and speak with) personal medical/dental information about my or my child's treatment to the individuals listed below. Unless specifically listed below, Hohl Orthodontics may not speak to any individual concerning the medical or financial information of this patient - including appointments, test results, prescriptions, school or work excuses, etc. This includes your spouse, children, children's step-parent, etc. WE MUST HAVE THEM LISTED BY NAME AND A SIGNATURE OF THE CUSTODIAL PARENT.

Communicable Disease Informed Consent

*You can complete one form for all children in the family

* Patient's Name:
* Parent/Guardian Name:
* Patient/Guardian Email:

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?
I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION. I grant authority to the Doctor and Staff to perform all procedures and treatments in my best interest. I authorize the Orthodontist to share treatment information with collaborating dentists and surgeons when appropriate. I authorize the Orthodontist to submit treatment information pertinent to this patient to the Insurance Company for billing purposes only. I understand that, when appropriate, Credit Bureau reports may be obtained.

There will be no charge for today's inital exam. If the patient elects to pursue treatment and diagnostic records are obtained, all diagnostic records will become part of the permanent record and therefore will become the financial responsibility of the patient (or parent/responsible party, if child is a minor). If any of these records need to be released from our office at any time, they will become your financial responsibility. A records release form will also need to be signed.

* Signature:
* Date: