Confidential Patient Information

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

Financial Party Information

Please update any insurance changes.

First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Email:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Social Security #:
Do you have insurance that covers orthodontics?
If so, please name the Insurance Company below:

Dental History

Dentist Name:
Check-up Frequency:
Last Dental Visit:
 
What is the patients main orthodontic concern?

Medical History

Physician Name:
Date of last Physical:
Patient Health:
Address:
City:
State:
Zip:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Any new diagnosis since your initial appointment:

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Patient's interest in treatment:
By typing my name I acknowledge and agree to this office's privacy practices. I know that I may request a copy of them for my records and may revoke my authorization in writing at any time.
By entering my name here I acknowledge that all the following information is accurate and true to the best of my knowledge:
Name:
Date:
Relation to patient: