Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Social Security #:
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
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:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Social Security #:
Birthdate:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Dental Insurance Information
Do you have dental insurance?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
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?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
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?
No
Yes
Have you ever experienced any unfavorable reaction to dentistry?
No
Yes
Have you ever lost or chipped any teeth?
No
Yes
Have there been any injuries to head, mouth, or teeth?
No
Yes
Is any part of your mouth sensitive to temperature or pressure?
No
Yes
Do your gums bleed when you brush?
No
Yes
Did you or do you have any type of thumb or tongue habit?
No
Yes
Are you a mouth breather?
No
Yes
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
No
Yes
Are you aware of your jaw clicking or popping?
No
Yes
Have you ever been told that you grind or clench your teeth?
No
Yes
Do you have "tension" headaches?
No
Yes
Have you ever had a speech problem / speech therapy?
No
Yes
Are there any problems, handicaps, or restrictions that may have a bearing on successful orthodontic treatment?
No
Yes
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?
No
Yes
Have you ever taken Bisphosphonates?
No
Yes
Are you allergic to any medications?
No
Yes
Do you have a history of major illness?
No
Yes
Have tonsils and/or adenoids been removed?
No
Yes
Have you had any major operations?
No
Yes
Have you been involved in a serious accident?
No
Yes
Are you allergic to Latex?
No
Yes
Are you currently being treated by another health professiona?
No
Yes
Do you require pre-medication for dental procedures?
No
Yes
Females: Are you pregnant or trying to become pregnant?
No
Yes
Please select YES or No for the medical conditions you currently have or have a history of - Do Not Leave Blank
Abnormal bleeding / Hemophilia
No
Yes
Anemia
No
Yes
Arthritis
No
Yes
Asthma / Hay fever / Allergy
No
Yes
Blood disorders
No
Yes
Diabetes
No
Yes
Dizziness
No
Yes
Endocrine disorders
No
Yes
Epilepsy
No
Yes
Gastrointestinal disorders
No
Yes
Heart defects / Murmur problems
No
Yes
Hepatitis / Liver problems
No
Yes
High blood pressure
No
Yes
HIV / AIDS
No
Yes
Kidney problems
No
Yes
Muscle disorders
No
Yes
Nervous disorders
No
Yes
Pneumonia
No
Yes
Radiation / Chemo / Cancer
No
Yes
Tuberculosis
No
Yes
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:
No
Yes
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative
Has either biological parent ever had orthodontic treatment:
Don't Know
Yes
No
Supplemental Informed Consent
Orthodontic Treatment in the Era of COVID-19
Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as "Coronavirus", at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.
Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant. "Social Distancing" nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, orthodontist, orthodontic staff and sometimes other patients at all times.
Although exposure is unlikely, do you accept the risk and consent to treatment?
Yes
No
To the best of my knowledge, all of the preceding questions have been accurately answered. If there is ever a change in the patient's health, or if their medications change, I will inform Trudy Bonvino DDS, MS at the next appointment.
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:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other