Confidential Patient Information

First Name:
MI:
Last Name:
Preferred Name:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Cell Phone:
Home Phone:
Work Phone:
Email:
Preferred Method of Contact
Place of Employement:
Occupation:

Spouse's Name:
Preferred Phone:
Place of Employement:
Occupation:

Your hobbies/interests:
Specific concerns about your smile:
Dentist:
Family members seen by us:
Whom may we thank for referring you?

Responsible Party

First Name:
Last Name:
Relationship to Patient:
Address:
City:
State:
Zip:
Cell Phone:
Home Phone:
Email:
Preferred Method of Contact

Primary Insured Name:
S.S. # of Insured:
Insurance Company:
Date of Birth:

Secondary Insured Name:
S.S. # of Insured:
Insurance Company:
Date of Birth:

Dental and Medical History

Concerns
Please select 'Yes' if the patient has any of the concerns listed below. Cannot be blank.
Crowding
Spacing
Misaligned teeth
Overbite
Protrusion of teeth
Receded jaw
Prominent jaw
Missing teeth
Periodontal (gum) disease
Irregular teeth (shape, color)
TMJ pain/disorder

Dental History
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Injury to teeth, jaw, or face?
Jaw or face pain?
Clicking, popping, or locking of jaw?
Clenches jaw/grinds teeth?
Thumb/finger habit?
Chews on object (nails, pens, other)?
Tongue thrust?
Mouth breathing?
Have you had a previous orthodontic evaluation?

Medical History
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
ADD/ADHD?
Asthma?
Autoimmune disorder?
Blood disease?
High blood pressure?
Bone disease/arthritis?
Diabetes?
Delayed growth?
Eating disorder?
Emotional concerns?
Endocrine disorder?
Epilepsy/Seizures/Fainting spells?
HIV+/AIDS?
Heart disease?
Heart murmur?
Hepatitis?
Hearing impairment?
Pregnant/possibly pregnant?
Speech impairment?
Tonsils/Adenoids removed?

Please list any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Latex?
Nickel?
Plastic?
Please list any other drug allergies or sensitivities that the patient may have:

Please provide any additional information you feel is important:

Emergency Contact Information

Name:
Phone:
Consent to Notice of Privacy Practices
Relationship to Patient:
Patient E-Signature:
Date: