Confidential Patient Information

You must be 18 years or older to complete this form, do you confirm you are 18 years or older?
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Social Security #:

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?

Financial Party Information

Financial Party First Name:
Financial Party Middle Initial:
Financial Party Last Name:
Financial Party Birthdate:
Relationship to Patient:
Email:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Social Security Number:
Do you have insurance that covers orthodontics? If so, please fill out the information below:
Insurance Company Name:
Insurance Company Phone:
Subscriber Name:
Subscriber Birthdate:
Subscriber ID or SSN:
Group Number:
Work Phone:
Length of Employment:

Dental History

Do you have a general dentist?
Dentist Name (if no dentist, type None):
Checkup Frequency:
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.
Apprehensive about dental care?
Brush teeth daily?
Clench or grind teeth?
Discomfort from teeth or gums?
Floss teeth daily?
Fluoride treatments?
Frequently chew gum?
Frequent headaches?
Frequent sore throats?
Injury to face, jaw, teeth, or mouth?
Missing or extra permanent teeth?
Mouth breathing?
Neck or shoulder pain?
Oral habits (thumb or finger sucking, lip or nail biting)?
Pain, tenderness, or noise in either jaw?
Requires premedication?
Snores during sleep?
Speech problems or therapy?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Do you have a physician?
Physician Name (if no physician, type None):
Date of Last Physical:
Patient Health:
Address:
City:
State:
Zip:
Please list any medications currently being taken by the patient (include non-prescription) (If none, type none.):
Please list any other drug allergies or sensitivities that the patient may have (If none, type none.):
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Anemia or blood disorder?
Arthritis or joint problems?
Asthma?
Bisphosphonates (Fosamax, Boniva)?
Bone disorders or loss?
Cancer?
Cancer in family history?
Diabetes?
Emotional problems treatment?
Endocrine problems?
Growth problems?
Handicaps or disabilities?
Heart attack or stroke?
Heart defect (congenital)?
Heart disease?
Heart murmur?
Hemophilia?
Hepatitis?
High blood pressure or hypertension?
HIV or AIDS?
Hormone therapy?
Ever been hospitalized?
Kidney disease?
Latex or Metal Allergy?
Liver disease, jaundice, or hepatitis?
Nervous disorders?
Pneumonia?
Prolonged bleeding or transfusion?
Radiation treatment?
Rheumatic fever?
Seizures, epilepsy, or neurological disease?
Tonsils or adenoids removed?
Tuberculosis or lung disease?
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:
Height:
Weight:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:

Has patient begun puberty?
If patient is a girl, has menstruation begun?
If patient is a boy, has their voice changed or have facial hair?
Has the patient grown in the past year or has their shoe size changed recently?
Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment:
Signature:
Date: