Confidential Patient Information

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

Financial Party Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Marital Status:
Address:
City:
State:
Zip:
How long at this address?
Previous Address (less than 3 years)
Email:
Main Phone:
2nd/Cell Phone:
Work Phone #:
Social Security #:
Employer:
Occupation:
Length of Employment:

Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Social Security #:
Birthdate:
Employer:
Occupation:
Length of Employment:
Work Phone #:

Dental Insurance Information

Do you have insurance that covers orthodontics?
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Birthdate:
Do you have dual dental coverage?
(If yes, complete information below)

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Birthdate:

Dental History

Dentist Name:
Last Dental Visit:

Please select YES or No for the Following Questions - Do Not Leave Blank
Are you currently in any dental pain?
Have you ever experienced any unfavorable reaction to dentistry?
Have you ever lost or chipped any teeth?
Have there been any injuries to head, mouth, or teeth?
Is any part of your mouth sensitive to temperature or pressure?
Do your gums bleed when you brush?
Did you or do you have any type of thumb or tongue habit?
Are you a mouth breather?
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
Are you aware of your jaw clicking or popping?
Have you ever been told that you grind or clench your teeth?
Do you have "tension" headaches?
Have you ever had a speech problem / speech therapy?
Are there any problems, handicaps, or restrictions that may have a bearing on successful orthodontic treatment?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of Last Physical:
Please list any medications (including over the counter), nutritional supplements, or herbal medications currently being taken by the patient, as well as what each is taken for:
Please select YES or No for the Following Questions - Do Not Leave Blank
Is your general health good at this time?
Have you ever taken Bisphosphonates?
Are you allergic to any medications?
Do you have a history of major illness?
Have tonsils and/or adenoids been removed?
Have you had any major operations?
Have you been involved in a serious accident?
Are you allergic to Latex?
Are you currently being treated by another health professiona?
Do you require pre-medication for dental procedures?
Females: Are you pregnant or trying to become pregnant?
Please select YES or No for the medical conditions you currently have or have a history of - Do Not Leave Blank
Abnormal bleeding / Hemophilia
Anemia
Arthritis
Asthma / Hay fever / Allergy
Blood disorders
Diabetes
Dizziness
Endocrine disorders
Epilepsy
Gastrointestinal disorders
Heart defects / Murmur problems
Hepatitis / Liver problems
High blood pressure
HIV / AIDS
Kidney problems
Muscle disorders
Nervous disorders
Pneumonia
Radiation / Chemo / Cancer
Tuberculosis

If any of the above medical questions were answered 'Yes' , please explain:
Is there any other health information about you that we should know about?

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Please list the name and birthdate of any siblings:
Height:
Weight:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:

Has the patient grown in the past year or has their shoe size changed recently:
Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment:
Signature on File
By signing below:
I authorize the use of this form and its information for all my insurance submissions.
I authorize this office and its employees to act as my agent in helping me obtain insurance reimbursement.
I authorize insurance payment directly to this office.
I authorize the use of a copy of this form which can be used in place of the original.
Signature of person completing form:
Relationship to Patient: