Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Home Phone:
Email:
If patient is a minor, give parent's or guardian's name(s)
Have other family members been patients here? If so, who?
What are the patient's interests (i.e. sports, hobbies, or musical instruments)?
How did you hear about us? Who referred you to our office?
Responsible Party/Legal Guardian Information
Check if the patient is also the person who will be 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
Birthdate:
Address:
City:
State:
Zip:
Previous address (if above less than 2 years)?
Email:
Home Phone:
Mobile Phone:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Work Phone:
Driver's license #:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Mobile Phone:
Work Phone:
If patient is a minor and parents are divorced or separated, with whom does the child live?
Name of non-custodial parent:
Phone:
Address of non-custodial parent
Dental Insurance Information
Insurance Company Name:
Policy Holder's Name:
Insurance Company Phone:
Subscriber ID:
Group Number:
Birthdate:
Medical History
Physician Name:
Phone:
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
Please list any medications currently being taken by the patient (include non-prescription):
Please list any drug allergies:
Metal allergies?
No
Yes
Latex alergies?
No
Yes
Any medication/antibiotic needed prior to dental procedure?
No
Yes
Have you ever taken Fosamax or bisphosphonates class of bone medicine?
No
Yes
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Adenoids removed?
No
Yes
AIDS/HIV?
No
Yes
Allergies/Sinus problems?
No
Yes
Anemia?
No
Yes
Arthritis?
No
Yes
Artificial heart valves?
No
Yes
Artificial joints?
No
Yes
Asthma?
No
Yes
Autistic disorder?
No
Yes
Blood/bleeding disorders?
No
Yes
Bone disorders?
No
Yes
Cancer?
No
Yes
Cardiac pacemaker?
No
Yes
Congenital heart lesions?
No
Yes
Chronic cough?
No
Yes
Diabetes?
No
Yes
Drug addiction?
No
Yes
Ear problems?
No
Yes
Eating disorders?
No
Yes
Emotional problems?
No
Yes
Endocrine disorders?
No
Yes
Epilepsy?
No
Yes
Faintness/dizziness?
No
Yes
Fever blisters?
No
Yes
Headaches (frequent)?
No
Yes
Heart murmur?
No
Yes
Heart trouble/condition?
No
Yes
Hepatitis?
No
Yes
Herpes?
No
Yes
High/low blood pressure?
No
Yes
Jaundice?
No
Yes
Joint swelling?
No
Yes
Kidney disease?
No
Yes
Organ Transplant?
No
Yes
Psychiatric treatment?
No
Yes
Radiation/chemo therapy?
No
Yes
Respiratory disease?
No
Yes
Rheumatic/scarlet fever?
No
Yes
Scoliosis?
No
Yes
Shortness of breath?
No
Yes
Seizures?
No
Yes
Speech problems?
No
Yes
Stroke?
No
Yes
Swelling of ankles?
No
Yes
Thyroid problems?
No
Yes
TMJ problems?
No
Yes
Tonsils removed?
No
Yes
Tuberculosis?
No
Yes
Venereal disease?
No
Yes
Whiplash?
No
Yes
FEMALES: Are You Pregnant?
No
Yes
Dental History
Dentist Name:
Date of last cleaning:
List any outstanding dental procedure that needs to be completed prior to orthodontic treatment:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Bad bite?
No
Yes
Bruxing/grinding teeth?
No
Yes
Cheek/lip chewing?
No
Yes
Clenching teeth?
No
Yes
Fingernail biting?
No
Yes
Injury to face/teeth?
No
Yes
Periodontal (gum) disease?
No
Yes
Missing/extra teeth?
No
Yes
Mouth breathing?
No
Yes
Morning jaw joint paint?
No
Yes
Pain/clicking in jaw joint?
No
Yes
Tongue thrust?
No
Yes
Previous orthodontic treatment?
No
Yes
Previous tooth extraction?
No
Yes
Smoking history?
No
Yes
Thumb/finger/lip sucking?
No
Yes
TMJ treatment?
No
Yes
Please list any other medical or dental condition/illness not listed above:
Patients Under 18
If patient is under the age of 18, please answer the following questions:
School & District:
Names and ages of siblings:
Has patient begun puberty?
No
Yes
Consent: I hereby authorize the doctor to take x-rays, study models, photographs, and to complete an orthodontic examination and make a thorough orthodontic diagnosis. We/I give consent to Dr. Rachel Thieberg and her staff to render orthodontic services on myself and/or my child as may in her professional judgment be necessary. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payments and deductibles that insurance does not cover. I further authorize this office to release all information necessary to secure the payment of benefits. I assign directly to the doctor all insurance benefits otherwise payable to me.
I understand that where appropriate, credit bureau reports may be obtained.