Child Patient Information

Today's Date:
First Name:
Middle Initial:
Last Name:
Sex:
Date of Birth:
Address:
City:
State:
Zip:
Home Phone:
Patient's Cell Phone:
Email:

Names of family members treated here:
Dental Provider:
Address:
Phone:
Who referred you to our office?
Are they our patient?

Responsible Party Billing Information

(Any orthodontic policy holder must be listed as a responsible party)
Title:
First Responsible Party First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Social Security Number:
Date of Birth:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
Employer's Name:
Work Phone:
How would you like to receive appointment reminders? Please choose 1.

Title:
Second Responsible Party First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Social Security Number:
Date of Birth:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
Employer's Name:
Work Phone:
How would you like to receive appointment reminders? Please choose 1.

Title:
Third Responsible Party First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Social Security Number:
Date of Birth:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
Employer's Name:
Work Phone:
How would you like to receive appointment reminders? Please choose 1.

Title:
Fourth Responsible Party First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Social Security Number:
Date of Birth:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
Employer's Name:
Work Phone:
How would you like to receive appointment reminders? Please choose 1.

Dental Insurance Information

Effective Date:
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Policy Holder's Date of Birth:

Do you have dual dental coverage?
(If yes, complete information below)
Effective Date:
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Policy Holder's Date of Birth:

Medical History

Physician Name:
Phone:
Date of Last Physical:
Address:
City:
State:
Zip:

Have their been any changes in your general health within the past year?
Is a physician for any reason treating you at present? If so, what is being treated?
What medicine(s) are you taking now?
Have you ever been hospitalized for any illness, accident, or surgery? If yes, when and why?
If a woman: Are you pregnant now?
Are you allergic to or have you had any unusual reactions to the following?
Penicillin?
Local dental anesthetics?
Barbiturates?
Codeine or other narcotics?
Aspirin?
Sedatives?
Sulfa drugs?
Latex or vinyl (glove)?
Metal (jewelry, etc.)?
Other?
Please list any other drug allergies or sensitivities that the patient may have:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Heart trouble?

(including heart murmurs, valve, prosthesis/pacemaker)

Rheumatic fever?
High/Low blood pressure?
Kidney problems?
Liver disease (hepatitis)?
Jaundice?
Diabetes?
Anemia, Sickle cell, Iron?
Prolonged bleeding?
Severe infections?
Epilepsy?
Fainting?
Convulsions?
Pneumonia?
Tuberculosis?
Venereal Disease, AIDS, ARC?
Arthritis?
Allergy, hay fever, hives?
Asthma?
Sinus problems?
Do you have any other disease, condition, or emotional problems you would like to bring to our attention?

Dental History

Have you ever had the following treatment?
*
Orthodontic (straightening of the teeth)? As a child or as an adult?
*
Extractions? If yes, how long ago, and for what reason(s)?
*
Periodontal treatment?
*
Mouthguard or splint (plastic device between your teeth)?
*
Treatment or surgery to change your bite?

Are you aware of any of the following conditions?
*
Sores, lumps or irritated areas in your mouth?
*
Food catching or collecting between your teeth?
*
Clenching or grinding your teeth?
*
Clicking, popping or grating noise in your jaw when chewing? Does it bother you?
*
Numbness or tingling in your mouth or face?
*
Would you change anything about your teeth or smile?

Over the past five years, how often have you been seen for teeth cleaning?
Last Dental Visit:
Dentist Name:

Authorizations

Insurance Information
Please provide us with your CURRENT orthodontic insurance information and we will be happy to assist you in filing your insurance claims. Please note that all payments are the responsibility of the primary responsible party, and an account will NOT be placed on hold awaiting benefits. In addition to this policy, our practice does NOT accept No-Fault insurance.
Financing Options
Our practice offers interest-free financing as well as free online pay for your orthodontic care. We accept all major credit cards and CARE CREDIT.
Records Release Authorization
I consent to the examination and treatment of by Dr. John Duthie and the staff of Duthie Orthodontics. I authorize DUTHIE ORTHODONTICS to release any and all diagnostic records, including but not limited to; records of office visits and treatment rendered, x-rays and photographs. Such records may be released to another dentist or orthodontist, or any other health care professional, for the purposes of discussing the patient's condition, consulting on said case, or reviewing dental records. These records may also be released to any governmental agencies, insurance companies, any managed care organizations which contract with my insurer for the purpose of pursuing payment, insurance reimbursement, submitting claims for services rendered or to be rendered. This authorization shall remain in effect for fifteen years from the date of submission.