Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Pronouns:
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

First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
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?
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?
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? 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?
Clench or grind teeth?
Injury to face, jaw, teeth, or mouth?
Pain, tenderness, or noise in either jaw?
Oral habits (thumb or finger sucking, lip or nail biting)?
Brush teeth daily?
Floss teeth daily?
Mouth breathing?
Snores during sleep?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Physician Phone #:
Date of Last Physical:
Patient Health:
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?
Anemia or blood disorder?
Asthma?
Autistic?
Bisphosphonates (Fosamax, Boniva)?
Bone disorders or loss?
Cancer?
Diabetes?
Endocrine problems?
Growth problems?
Heart attack or stroke?
Heart defect (congenital)?
Heart Condition?
Heart murmur?
Hemophilia?
Hepatitis?
High blood pressure or hypertension?
HIV or AIDS?
Hormone therapy?
Kidney disease?
Latex or Metal Allergy?
Liver disease, jaundice, or hepatitis?
Pneumonia?
Prolonged bleeding or transfusion?
Radiation treatment?
Rheumatic fever?
Seizures, epilepsy, or neurological disease?
Smoking/Tobacco Use?
Tonsils or adenoids removed?
Tuberculosis or lung disease?
Other? Please specify below.
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:
Has either biological parent ever had orthodontic treatment: