Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Date of Birth:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Phone:
Home Phone:
Email:
Family members treated at Giardina Orthodontics:
What school do you attend?
How did you hear about our practice?
Whom may we thank for referring you to our office?
Responsible Party
Check if the patient is also financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Date of Birth:
Address:
City:
State:
Zip:
Phone:
Home Phone:
Email:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Responsible Party #2 First Name:
Middle Initial:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Date of Birth:
Address:
City:
State:
Zip:
Phone:
Home Phone:
Email:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Dental Insurance Information
Does your insurance cover orthodontic treatment?
No
Yes
Policy Holder's Name:
Policy Holder's Employer:
Date of Birth:
Address:
City:
State:
Zip:
Insurance Company Name:
SSN# ID#:
Group Number:
Insurance Company Address:
City:
State:
Zip:
I certify that I (or my dependent) have insurance coverage and assign directly to Giardina Orthodontics all insurance benefits, if any, otherwise payable to me for servies rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of the signature located on the back of this form on all insurance submissions.
Patient Dental History
Dentist Name:
Checkup Frequency:
Less than once per year
Once per year
Twice per year
Last Dental Visit:
Preferred Oral Surgeon:
Has the patient had previous orthodontic treatment?
No
Yes
What is the patient's main orthodontic concern?
Please select 'Yes' for any conditions the patient currently has or has had previously. Cannot be blank.
Speech problems or therapy?
No
Yes
Discomfort from teeth or gums?
No
Yes
Frequent sore throats?
No
Yes
Grind or clench teeth?
No
Yes
Requires premedication?
No
Yes
Fluoride treatments?
No
Yes
Oral habits (thumb or finger sucking, lip or nail biting)?
No
Yes
Pain, tenderness, or noise in either jaw?
No
Yes
Snores during sleep?
No
Yes
Injury to face, jaw, teeth, or mouth?
No
Yes
Frequent headaches?
No
Yes
Mouth breathing?
No
Yes
Missing or extra permanent teeth?
No
Yes
Neck or shoulder pain?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Patients Under 18
Skip this section if it does not apply
Has patient begun puberty?
No
Yes
If patient is female, has menstruation begun?
No
Yes
If patient is male, has their voice changed or have facial hair?
No
Yes
In the past year, has the patient grown or changed shoe size?
No
Yes
Patient's interest in treatment?
Interested
Not Interested
Indifferent
Has either biological parent ever had orthodontic treatment?
Don't know
No
Yes
Patient Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Are You Pregnant?
No
Yes
Please list any medications currently being taken by the patient (include non-prescription):
Please list any drug allergies or sensitivities that the patient may have:
Please select 'Yes' for any conditions the patient currently has or has had previously. Cannot be blank.
Ever Been Hospitalized?
No
Yes
ADD/ADHD/Touretts?
No
Yes
Anemia?
No
Yes
Arthritis?
No
Yes
Asthma?
No
Yes
Bone Disorders or Loss?
No
Yes
Cancer?
No
Yes
Cancer in Family History?
No
Yes
Comfortable with Dogs?
No
Yes
Congenital Heart Defect?
No
Yes
Diabetes?
No
Yes
Eating Disorder?
No
Yes
Emotional Problems Treatment?
No
Yes
Endocrine Problems?
No
Yes
Growth Problems?
No
Yes
Handicaps or Disabilities?
No
Yes
Heart Attack or Stroke?
No
Yes
Heart Disease?
No
Yes
Heart Murmur?
No
Yes
Hemophilia?
No
Yes
Hepatitis?
No
Yes
HIV or AIDS?
No
Yes
Hormone Therapy?
No
Yes
Hypertension or High Blood Pressure?
No
Yes
Kidney Disease?
No
Yes
Latex/Metal Allergy?
No
Yes
Nervous Disorders?
No
Yes
Pneumonia?
No
Yes
Prolonged Bleeding or Transfusion?
No
Yes
Received Radiation Treatment?
No
Yes
Seizures or Epilepsy?
No
Yes
Smoker or Use Tobacco Products?
No
Yes
Tonsils or Adenoids Removed?
No
Yes
Tuberculosis or Lung Disease?
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Authorization to Release Information
Information or Records to be disclosed: All health care information, appointments, communications, prescriptions, and any other aspect related to the patient's health care or the contents of the medical records.
Please list persons to whom disclosure is to be made to other than Responsible Party:
Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Phone:
Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Phone:
Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Phone:
Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Phone:
Authorization for Patient X-rays
In providing the best treatment for our patients, it might be necessary for us to e-mail x-rays to other specialists or dentists. This allows other offices to have a better diagnostic tool available to them which will cost you less and permit you to have access to quicker service.
I understand that x-rays might need to be e-mailed to other dentists or specialists. I give my permission for this service.
I do NOT give my permission for this service and take full responsibility for transferring x-rays between dentists.
Authorization for Patient Communication
Giardina Orthodontics would like to offer you the ability to receive text message or email reminders for your appointments. I agree to allow Giardina Orthodontics to contact me in the following manner:
Email reminders sent to:
Text message reminders sent to:
Authorization for Patient Photos
Giardina Orthodontics likes to share our fun with others through photos posted on social media as well as around the office. I agree to allow Giardina Orthodontics to post photos of me in the following manner:
Photos may be posted in the office and on social media.
Photos may NOT be used for anything other than medical purposes.
By entering my name below, I confirm that I have reviewed Giardina Orthodontics Privacy Practices.
Click here to review
I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.