Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Pronouns:
She/Her
He/Him
They/Them
Please use my name
Father/Guardian Name:
Mother/Guardian Name:
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?
Responsible Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Email:
Address:
City:
State:
Zip:
Cell Phone:
2nd Phone:
We're happy to verify your orthodontic benefits prior to your appointment. Don't worry if you don't have insurance coverage. We're experts at finding a payment plan that works for your budget!
(Please type N/A in required fields where applicapble.)
Do you have Dental insurance that covers orthodontics?
No
Yes
If so, please name the Dental Insurance Company:
Policy Holder Name:
Policy Holder DOB:
Policy Holder's SSN:
Employer:
Member/Subscriber ID#:
Group #:
Ins. Company Phone #:
Do you have Secondary Dental Insurance?
No
Yes
If so, please name the Dental Insurance Company:
Policy Holder Name:
Policy Holder DOB:
Policy Holder's SSN:
Employer:
Member/Subscriber ID#:
Group #:
Ins. Company Phone #:
Dental History
Dentist Name:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
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.
Speech problems or therapy?
No
Yes
Clench or grind teeth?
No
Yes
Injury to face, jaw, teeth, or mouth?
No
Yes
Pain, tenderness, or noise in either jaw?
No
Yes
Oral habits (thumb or finger sucking, lip or nail biting)?
No
Yes
Brush teeth daily?
No
Yes
Floss teeth daily?
No
Yes
Mouth breathing?
No
Yes
Snores during sleep?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Physician Phone #:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Please list any medications currently being taken by the patient (include non-prescription):
Please list any other drug allergies or sensitivities that the patient may have:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
ADHD?
No
Yes
Anemia or blood disorder?
No
Yes
Asthma?
No
Yes
Autistic?
No
Yes
Bisphosphonates (Fosamax, Boniva)?
No
Yes
Bone disorders or loss?
No
Yes
Cancer?
No
Yes
Diabetes?
No
Yes
Endocrine problems?
No
Yes
Growth problems?
No
Yes
Heart attack or stroke?
No
Yes
Heart defect (congenital)?
No
Yes
Heart Condition?
No
Yes
Heart murmur?
No
Yes
Hemophilia?
No
Yes
Hepatitis?
No
Yes
High blood pressure or hypertension?
No
Yes
HIV or AIDS?
No
Yes
Hormone therapy?
No
Yes
Kidney disease?
No
Yes
Latex or Metal Allergy?
No
Yes
Liver disease, jaundice, or hepatitis?
No
Yes
Pneumonia?
No
Yes
Prolonged bleeding or transfusion?
No
Yes
Radiation treatment?
No
Yes
Rheumatic fever?
No
Yes
Seizures, epilepsy, or neurological disease?
No
Yes
Smoking/Tobacco Use?
No
Yes
Tonsils or adenoids removed?
No
Yes
Tuberculosis or lung disease?
No
Yes
Other? Please specify below.
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
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:
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative
Has either biological parent ever had orthodontic treatment:
Don't Know
Yes
No