Patient Information
First Name:
Last Name:
Birthdate:
Address:
City:
State:
Zip:
First Name of Person Responsible for Account:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Home Phone:
OK to leave message?
No
Yes
Cell Phone:
OK to leave message?
No
Yes
OK to text?
No
Yes
We have found that the best way to stay in contact is through texting – You can text us at any time using our office number (865-522-0121)
Email:
Emergency Contact Name:
Phone:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Dental Insurance Information
Insurance Company Name:
Insurance Company Phone:
Group Number:
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Subscriber ID:
Social Security Number:
Birthdate:
Policy Holder's Employer:
Work Phone:
Insurance Company Name:
Insurance Company Phone:
Group Number:
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Subscriber ID:
Social Security Number:
Birthdate:
Policy Holder's Employer:
Work Phone:
Dental History
Dentist Name:
Have you visited an orthodontist before?
No
Yes
Patient's Oral Health:
Good
Fair
Poor
Do you have regular dental check-ups?
No
Yes
When was the last check-up?
Do you clench/grind your teeth?
No
Yes
Do you have pain/tenderness/clicking in your jaw joint (TMJ)?
No
Yes
Frequent headaches?
No
Yes
Do you have any oral habits (thumb or finger sucking, lip or nail biting)?
No
Yes
Speech problems or therapy?
No
Yes
Mouth breathing?
No
Yes
Have you had any injury to your neck, jaw, or teeth? If yes, please explain:
No
Yes
Has anyone in your family had braces? If yes, list name and relationship:
No
Yes
Medical History
Physician Name:
Please rate your overall health:
Good
Excellent
Fair
Poor
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
Are you taking any prescription or over-the-counter drugs? Please list:
Are you allergic to any drugs or other substances (including heavy metals or latex)? Please list:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Abnormal bleeding?
No
Yes
AIDS?
No
Yes
Anemia?
No
Yes
Asthma?
No
Yes
Cancer?
No
Yes
Chicken Pox?
No
Yes
Congenital heart defect?
No
Yes
Convulsions?
No
Yes
Diabetes?
No
Yes
Epilepsy?
No
Yes
Heart murmur?
No
Yes
Hemophilia?
No
Yes
Hepatitis?
No
Yes
High blood pressure?
No
Yes
HIV+?
No
Yes
Kidney problems?
No
Yes
Low blood pressure?
No
Yes
Rheumatic fever?
No
Yes
Skin rash?
No
Yes
Tonsillitis?
No
Yes
Tuberculosis (TB)?
No
Yes
Are you Pregnant or Nursing?
No
Yes
Are there any other medical concerns we should be aware of?
Has your physician told you that you need to be premedicated with an antibiotic before dental procedures? If yes, list condition and antibiotic:
No
Yes
I understand that the information provided today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is MY responsibility to inform the office of any changes in my medical status.
I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payments of any benefits to the office of Langford Orthodontics. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY INSURANCE (FOR ANY REASON)
I grant Langford Orthodontics, its representatives and employees the right to take photographs or video of me or my child(ren). I authorize Langford Orthodontics, its assigns and transferees to copyright, use and publish the same in print or electronically.
I agree that Langford Orthodontics may use such photographs and video of me or my child(ren) with or without my name and for any lawful purpose, including for examples such as publicity, illustration, advertising, Web content and social media content.
I have read and understand the
Office Policy
.