Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Preferred Name:
Gender:
Male
Female
Birthdate:
Social Security #:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email Address:
Employer:
Occupation:
Emergency Contact First Name:
Emergency Contact Last Name:
Emergency Contact Patient Relation:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Emergency Contact Phone:
Hobbies/Interests:
If a Student, Grade:
School:
Check status:
Minor
Single
Married
Separated
Divorced
Widowed
If a minor, please give parent’s or guardian’s name:
Whom may we thank for referring you to our office?
Financial Party Information
Check here if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Birthdate:
Social Security #:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email Address:
Employer:
Occupation:
Patient Relation:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Spouse Information
If not applicable, please check here.
First Name:
Middle Initial:
Last Name:
Birthdate:
Social Security #:
Address (if different):
City:
State:
Zip:
Home Phone:
Cell Phone:
Email Address:
Employer:
Occupation:
Patient Relation:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Dental Insurance Information
Policy Holder's First Name:
Middle Initial:
Last Name:
Patient Relation:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Subscriber ID #:
Insurance Company:
Group #:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Employer:
Do you have dual dental coverage?
Yes
No
(If yes, complete information below)
Secondary Dental Insurance
Policy Holder's First Name:
Middle Initial:
Last Name:
Patient Relation:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Subscriber ID #:
Insurance Company:
Group #:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Employer:
Dental History
Dentist's Name:
Last Dental Visit:
Checkup Frequency:
>2x/year
2x/year
1x/year
Emergencies only
Is all dental work completed?
Yes
No
If no, please explain:
Has the patient ever had an orthodontic consult or treatment?
Yes
No
If yes, when?
What is the patient's main orthodontic concern?
Dental Conditions
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Apprehensive about dental care?
Yes
No
Trauma to mouth, teeth, or face?
Yes
No
Speech problems or speech therapy?
Yes
No
Teeth sensitive to hot or cold?
Yes
No
Thumb or finger sucking?
Yes
No
Food frequently trapped between teeth?
Yes
No
Lip or nail biting?
Yes
No
Teeth that irritate tongue, cheeks, or lips?
Yes
No
Abnormal swallowing or tongue thrust?
Yes
No
Pain, tenderness, or noise in either jaw joint?
Yes
No
Mouth breathing?
Yes
No
History of jaw joint problems?
Yes
No
Missing or extra permanent teeth?
Yes
No
TMJ (temporomandibular joint) screening?
Yes
No
Previous periodontal (gum) treatment?
Yes
No
Has patient been treated for “TMJ”/TMD?
Yes
No
Please describe any other dental concerns and explain any 'Yes' answers as needed:
Medical History
Physician's Name:
Date of last exam:
Physician's Address:
City:
State:
Zip:
Patient's Health:
Good
Fair
Poor
Any changes in the patient’s general health within the last year?
Yes
No
If yes, please explain:
Is the patient under the care of a physician for anything?
Yes
No
If yes, please explain:
Please list any medications currently being taken by the patient (include non-prescription):
Has the patient ever used alcohol, tobacco, or illicit drugs?
Yes
No
If yes, describe type, frequency, and amount:
Does the patient need antibiotic pre-medication prior to dental visits?
Yes
No
If yes, please describe type and reason:
Allergies and Medical Conditions:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Latex Allergy?
Yes
No
Metal or Nickel Allergy?
Yes
No
Food Allergy?
Yes
No
Heart Disease?
Yes
No
Cancer/Family History?
Yes
No
Chemo/Radiation Therapy?
Yes
No
Prosthetic Joints?
Yes
No
Bisphosphonate Use?
Yes
No
FEMALES: Pregnant?
Yes
No
Please describe any other medical conditions or concerns and explain any 'Yes' answers as needed:
Patients Under 18
If the patient is under the age of 18, please answer the following questions:
Height:
Feet:
Inches:
Weight:
Pounds:
Has the patient begun puberty?
Yes
No
Don't Know
Has the patient grown or increased shoe size in the past year?
Yes
No
Don't Know
Has either biological parent ever had orthodontic treatment?
Yes
No
Don't Know
Initials:
I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that it is my responsibility to inform this office of any changes. I will not hold my orthodontist or any other member of the staff responsible for any errors or omissions that I may have made in the completion of this form.
Initials:
I understand that my Social Security Number will need to be on file should I decide to finance through the office.