Patient's Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:

Emergency Contact's Name
Relationship to Patient:
Phone #:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Place of employment or School and Grade

Person Responsible for Account

First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Birthdate:
Social Security #:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Employer:
Occupation:
Length of Employment:

Secondary's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Birthdate:
Social Security #:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Employer:
Occupation:
Length of Employment:

Insurance Information

Insurance Company:
Policy Holder's Name:
Relationship to Patient:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone Number:
Subscriber ID #:
Group No.:
Policy Holder's DOB:
SSN:
Do you have dual dental coverage?
(If yes, complete information below)

Secondary Insurance Company:
Policy Holder's Name:
Relationship to Patient:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone Number:
Subscriber ID #:
Group #:
Policy Holder's DOB:
SSN:

Dental and Health History

All past medical and dental history may be important for optimal care. Please take time to be as accurate and thorough as possible in answering the following questions. THANK YOU.

How did you discover our office?
How can we help you? We need to know more about your reasons for visiting our office. Please answer the following questions to the best of your ability.
Are you satisfied with the way the teeth look?
If no, please tell us what you would like to see changed. (Try to be specific: too big, too small, discolored, spaced, crowded…)
Do you have any concerns about the bite or the way the teeth fit together?
If yes, please tell us about your concerns. (Try to be specific: overbite, underbite, teeth fail to meet on biting, biting cheeks, etc.)
Do you have any concerns about the facial appearance/profile?
If yes, please tell us what you would like to see changed. (Try to be specific: upper/lower jaw(s) moved forward/backward, show less gum when smiling, move lips forward/back…)
Teeth can be moved with either braces or clear aligners. If the same result is achievable with both methods, do you have a preference between braces and clear aligners?
Dental Background:

Dentist Name:
Date of Last Cleaning:
If the answer is “Yes” to any of the following questions for the patient, please describe:
Any dental work that is yet to be completed?
Previous orthodontic consultation or treatment?
Injuries or trauma to jaws or teeth?
Tooth sensitivity (hot, cold, sweets)?
Missing Teeth?
Jaw joint discomfort?
Jaw joint clicking or popping?
Treatment for jaw joint symptoms (splints, medications)?
Suck thumb, fingers, blanket, pacifier?
Negative or resistant feeling about orthodontic treatment?
Has any member of the family had orthodontic treatment?
Medical Information:

Allergy to any medications?
Do you have a latex allergy?
Any health circumstance requiring antibiotics prior to dental procedures?
Diabetes?
If yes, Type 1 or Type 2?
Medication:
Arthritis or rheumatism?
Growth delay?
If yes, is medication required?
Early maturation?
If yes, is medication required?
Is the patient pregnant or possibly pregnant?
Hormone Therapy?
If yes, please describe:
Periodic MRI scans of the head/neck region?
If yes, please describe:
Autistic or on the spectrum?
If yes, what do we need to know to best serve the patient?
Please list all medications the patient is currently taking:
Any medical situation not listed above that may be relevant to orthodontic treatment:
Signature:
Date:

Notice of Privacy Policy

I have reviewed a copy of the Varble Orthodontics Notice of Privacy Practices. Click here to review

Release

I authorize Dr. Zachary L. Varble and his orthodontic staff to perform diagnostic procedures and treatment as may be necessary for proper orthodontic care.

I authorize release of any information concerning my (or my child's) health care for advice and treatment provided for evaluation and administering claims for insurance benefits.

I authorize release of any information concerning my (or my child's) health care for advice treatment to interdisciplinary team members.

I authorize the taking of photographs and other diagnostic records before, during and after treatment.

The above information is accurate and complete to the best of my knowledge.