Confidential Patient Information

* First Name:
Middle Initial:
* Last Name:
Nickname:
* Birthdate:
* Gender:
* Address:
* City:
* State:
* Zip:
* Main Phone:
2nd/Cell Phone:
Email:
How do you prefer to receive appointment reminders?

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 18

If patient is under the age of 18, please answer the following questions:
Please list the name and birthdate of any siblings:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
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:
* Address:
* City:
* State:
* Zip:
* Main Phone:
2nd/Cell Phone:
Social Security #:

Primary Insurance

Insurance Company Name:
Subscriber Name:
Subscriber ID:
Subscriber Date of Birth:

Secondary Insurance

Insurance Company Name:
Subscriber Name:
Subscriber ID:
Subscriber Date of Birth:

Medical History

Physician Name:
Date of last Physical:
Patient Health:
Address:
City:
State:
Zip:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select YES or No for the Following Questions - Do Not Leave Blank
* ADHD
* Autism
* Celiac
* Herpes
* Down Syndrome
* Gastrointestinal_Disorder
* Tuberculosis/Lung Disease
* Pneumonia
* Liver Problems
* Kidney Problems
* Heart Problems
* Hemophilia
* Hypertension/High Blood Pressure
* Anemia
* HIV/AIDS
* Hepatitis
* Tonsils/Adenoids Removed
* Cancer
* Growth Problems
* Endocrine Problems
* Latex/Metal Allergy
* Nervous Disorders
* Bone Disorders/Bone Loss
* Diabetes
* Seizures/Epilepsy
* Asthma
* Arthritis
* Ever Been Hospitalized
* Take Bisphosphonates (Fosamax, Boniva)
If any of the above medical questions were answered 'Yes' , please explain:

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 patients main orthodontic concern?

Please select YES or No for the Following Questions - Do Not Leave Blank
* Speech problems/therapy?
* Grind or clench teeth?
* Injury to face, jaw, teeth or mouth?
* Discomfort from teeth or gums?
* Pain, tenderness or noise in either jaw?
* Oral habits (thumb/finger sucking, lip/nail biting)?
* Frequent sore throats?
* 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:
What are your primary concerns in considering orthodontic treatment? (Please check all that apply)
Other
How familiar are you with orthodontic treatment?


If other, please explain:
We want to make sure your appointment meets your needs. Which best describes how you like to receive information?


If other, please explain:
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