Confidential Patient Information (New Patients)

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

Please list the names of any friends or family who are or have been patients in our practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
What is the patient's main orthodontic concern?
Patient's interest in treatment:

Financial Party Information

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 not please write "None" for required questions)
If so, please name the Insurance Company:
Member ID Number:
Group ID Number:
Responsible Party:
Employer:

Dental History

Dentist Name:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
If so, when?

Please respond to the following by selecting YES or No (if YES, please fill in details). Parents/guardians please respond for minors.
Injuries to face, jaw, mouth, or teeth?
Missing or extra permanent teeth?
Thumb or tongue habit?
Frequent pain, tenderness, or noise in jaw?
Habits such as grinding or clenching?
Need for premedication before dental procedures?
Loud snoring during sleep?

Medical History

Please respond to the following by selecting YES or No (if YES, please fill in details). Parents/guardians please respond for minors.
Are you taking any medications/supplements?
Are you taking or have you ever taken bisphosphonates for osteoporosis or other bone diseases?
Are you allergic to any medication/latex/metals/materials/anesthetics?
Do you have a history of a major illness, operation, or accident?
Does your physician recommend premedicating with antibiotics prior to dental procedures?
If you have any of the following conditions, please explain in the box below:
Abnormal bleeding/ hemophilia, anemia, arthritis, asthma or hay fever, bone disorders, cancer, chemotherapy treatment, congenital heart defects, diabetes, dizziness, epilepsy, gastrointestinal disorders, growth disorders, heart problems or heart murmur, hepatitis or liver problems, herpes, high blood pressure or hypertension, HIV/AIDS, hormone therapy, kidney problems, nervous disorders, pneumonia, radiation treatment, rheumatic fever, sleep apnea, stroke, tuberculosis, tumor
Female patients only:
Are you pregnant?
If patient is under 16, has menstruation started?
If menstruation has begun, please indicate month/year it began:
Signature
Date