Patient Information
First Name:
Last Name:
Gender:
Male
Female
Other
DOB:
Cell Phone:
Email:
Home Phone:
Address:
Apt#:
City:
State:
Zip:
Social Security #:
Describe main concerns about your teeth/smile:
How did you hear about Diamond Braces? (If you were referred by a Diamond Braces employee, please add their name below.)
What type of treatment are you most interested in?
Invisalign
Clear Braces
Metal Braces
Other
Insurance Information
Insurance Company Name:
Subscriber's Name:
Subscriber's ID:
Subscriber's DOB:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Employer:
If any alternative (secondary) coverage, please fill out the below:
Insurance Company Name:
Subscriber's Name:
Subscriber's ID:
Subscriber's DOB:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Employer:
Dental History
Have you ever had an orthodontic consultation or treatment before?
Yes
No
If yes, when and where?
Do you have a general dentist?
Yes
No
Dentist Name:
Dentist Phone:
Last Dental Visit:
Presently in dental pain?
Yes
No
Injury to face, jaw, teeth, or mouth?
Yes
No
Bleeding gums?
Yes
No
Oral Habits?
Yes
No
Are you brushing and flossing daily?
Yes
No
Do you require premedication before dental visit?
No
Yes
Please describe any dental concerns or conditions we should know about:
Medical History
Please list any medications you are currently taking:
Are you allergic to latex or nickel?
Yes
No
Please list any major illnesses you have had:
Abnormal Bleeding/Hemophilia?
Yes
No
Anemia or blood disorder?
Yes
No
Asthma/Hayfever?
Yes
No
Attention Deficit Disorder?
Yes
No
Autism?
Yes
No
Bone Disorders?
Yes
No
Cancer?
Yes
No
Congential Heart Defect?
Yes
No
Developmental Delay?
Yes
No
Diabetes?
Yes
No
Emotional Disorders?
Yes
No
Epilepsy?
Yes
No
Genetic Disorders?
Yes
No
Heart Problems?
Yes
No
Heart Murmur?
Yes
No
Hepatitis?
Yes
No
Herpes?
Yes
No
High Blood Pressure?
Yes
No
HIV/AIDS?
Yes
No
Nervous Disorders?
Yes
No
Pregnant?
Yes
No
Radiation/Chemotherapy?
Yes
No
Tuberculosis?
Yes
No
Other Conditions?