Patient Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Address:
City:
State:
Zip:
Years at above address?
Social Security Number:
Email:
Home Phone:
Cell Phone:
Whom may we thank for referring you to our office?
Who do you authorize to discuss your child’s treatment?
Who do you authorize to discuss financial info?

Financial Party Information

First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Birthdate:
Address:
City:
State:
Zip:
How long at this address?
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:
Cell Phone:

Insurance Information

Primary
Dental Insurance:
Phone:
Policy Holder's Name:
Birthdate:
Subscriber ID:
Group Number:
Secondary
Dental Insurance:
Phone:
Policy Holder's Name:
Birthdate:
Subscriber ID:
Group Number:

Emergency Contact Information

Name of nearest relative not living with you:
Address:
Phone:

Medical History

Physician Name:
Date of Last Visit:
City, State:
Phone:

Please select Yes or No (If Yes, please fill in details)
Are you taking any medication?
Are you allergic to any medication?
Do you have a history of a major illness?
Have you had any major operations?
Have you ever been involved in a serious accident?
Please select Yes or No to any of the medical conditions below that you have had or currently have.
Abnormal bleeding / Hemophilia?
Anemia or blood disorder?
Arthritis?
Asthma or Hayfever?
Bone disorders?
Congenital Heart Defect?
Diabetes?
Dizziness?
Epilepsy?
Gastrointestinal Disorder?
Heart Problems?
Heart murmur?
Hepatitis/Liver Problems?
Herpes?
High Blood Pressure?
HIV / AIDS?
Kidney Problems?
Nervous Disorders?
Pneumonia?
Prolonged Bleeding?
Radiation / Chemotherapy?
Rheumatic Fever?
Tuberculosis?
Tumor or Cancer?
Are there any medical conditions we have not discussed that you feel we should be aware of?
Are you allergic to latex?

Dental History

Dentist Name:
Last Dental Visit:
What concerns you most about your teeth?

Are you presently in any dental pain?
Have you ever experienced any unfavorable reaction to dentistry?
Have you ever lost or chipped any teeth?
Have there been any injuries to face, mouth, or teeth?
Is any part of your mouth sensitive to temperature or pressure?
Do your gums bleed when you brush?
Do you have any type of thumb or tongue habit?
Are you a mouth breather?
Have you ever seen an orthodontist? If yes, who and when?
What is your attitude toward receiving orthodontic treatment?
Has anyone in your family received orthodontic treatment? How did they feel about the result?
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
Are you aware of your jaw clicking or popping?
Are you aware of clenching your teeth during the day?
Do you have "tension" headaches?
Have you ever experienced chronic ringing in your ears?
If the patient is under age 16, height of parents?
Mom: Dad:
Are you aware that some appointments will be during school/work hours?
Please list some hobbies or interests:
Female Patients only:
Are you pregnant?
Has menstruation started?

Benefits

Benefits of Orthodontics: 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 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 also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Housley and/or Dr. Dobson to perform a complete orthodontic evaluation.
Signature: