Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Date of Birth:
Gender:
Address:
City:
State:
Zip:
Cell Phone:
Home Phone:
Email:

Family members treated at Kray 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

First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Date of Birth:
Address:
City:
State:
Zip:
Cell Phone:
Home Phone:
Email:
Social Security Number:
Employer:
Occupation:
Length of Employment:

Responsible Party #2 First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Date of Birth:
Address:
City:
State:
Zip:
Cell Phone:
Home Phone:
Email:
Social Security Number:
Employer:
Occupation:
Length of Employment:

Dental Insurance Information

Does your insurance cover orthodontic treatment?
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 Kray 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:
Last Dental Visit:
Has the patient had previous orthodontic treatment?
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?
Discomfort from teeth or gums?
Frequent sore throats?
Grind or clench teeth?
Requires premedication?
Fluoride treatments?
Oral habits (thumb or finger sucking, lip or nail biting)?
Pain, tenderness, or noise in either jaw?
Snores during sleep?
Injury to face, jaw, teeth, or mouth?
Frequent headaches?
Mouth breathing?
Missing or extra permanent teeth?
Neck or shoulder pain?
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?
If patient is female, has menstruation begun?
If patient is male, has their voice changed or have facial hair?
In the past year, has the patient grown or changed shoe size?
Patient's interest in treatment?
Has either biological parent ever had orthodontic treatment?

Patient Medical History

Physician Name:
Date of Last Physical:
Patient Health:
Are You Pregnant?
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?
ADD/ADHD/Touretts?
Anemia?
Arthritis?
Asthma?
Bone Disorders or Loss?
Cancer?
Cancer in Family History?
Congenital Heart Defect?
Diabetes?
Eating Disorder?
Emotional Problems Treatment?
Endocrine Problems?
Growth Problems?
Handicaps or Disabilities?
Heart Attack or Stroke?
Heart Disease?
Heart Murmur?
Hemophilia?
Hepatitis?
HIV or AIDS?
Hormone Therapy?
Hypertension or High Blood Pressure?
Kidney Disease?
Latex/Metal Allergy?
Nervous Disorders?
Pneumonia?
Prolonged Bleeding or Transfusion?
Received Radiation Treatment?
Seizures or Epilepsy?
Smoker or Use Tobacco Products?
Tonsils or Adenoids Removed?
Tuberculosis or Lung Disease?
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:
Phone:
Name:
Relationship to Patient:
Phone:
Name:
Relationship to Patient:
Phone:
Name:
Relationship to Patient:
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.

Authorization for Patient Communication

Kray Orthodontics would like to offer you the ability to receive text message or email reminders for your appointments. I agree to allow Kray Orthodontics to contact me in the following manner:

Authorization for Patient Photos

Kray Orthodontics likes to share our fun with others through photos posted on social media as well as around the office. I agree to allow Kray Orthodontics to post photos of me in the following manner: