Patient Biographical Information

Please be sure and capitalize the first letter of every word when filling out this section. (i,e, Oklahoma City)

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Main Phone:
Phone Type:
2nd/Cell Phone:
Phone Type:
Email used for appointment reminders:
Social Security Number (If you don't know the Soonercare ID if applicable or if patient is also the responsible party):

Please list the names of any family members being seen in our practice in order to see them all in the Patient Portal:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?

Financial Party Information

Please be sure and capitalize the first letter of every word when filling out this section. (i,e, Oklahoma City)

First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Email used for receipts and appointment reminders:
Address:
City:
State:
Zip:
Main Phone:
Phone Type:
2nd/Cell Phone:
Phone Type:
Social Security Number:

Dental Insurance Information

Please be sure and capitalize the first letter of every word when filling out this section. (i,e, Oklahoma City)

 
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:

Do you have dual dental coverage?
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:

Dental History

Please be sure and capitalize the first letter of every word when filling out this section. (i,e, Oklahoma City)

Dentist Name:
Checkup Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when?
What is the patient's main orthodontic concern?

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?
Brush teeth daily?
Clench or grind teeth?
Discomfort from teeth or gums?
Floss teeth daily?
Fluoride treatments?
Frequently chew gum?
Frequent headaches?
Frequent sore throats?
Injury to face, jaw, teeth, or mouth?
Missing or extra permanent teeth?
Mouth breathing?
Neck or shoulder pain?
Oral habits (thumb or finger sucking, lip or nail biting)?
Pain, tenderness, or noise in either jaw?
Requires premedication?
Snores during sleep?
Speech problems or therapy?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Please be sure and capitalize the first letter of every word when filling out this section. (i,e, Oklahoma City)

Physician Name:
Date of Last Physical:
Patient Health:
Address:
City:
State:
Zip:
Please list any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Aspirin, Ibuprofen, or Tylenol?
Codeine or other narcotics?
Latex?
Local anesthetics?
Metal?
Penicillin or other antibiotics?
Sulfa drugs?
Other?
Please list any other drug allergies or sensitivities that the patient may have:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Anemia or blood disorder?
Arthritis or joint problems?
Asthma?
Bisphosphonates (Fosamax, Boniva)?
Bone disorders or loss?
Cancer?
Cancer in family history?
Diabetes?
Emotional problems treatment?
Endocrine problems?
Growth problems?
Handicaps or disabilities?
Heart attack or stroke?
Heart defect (congenital)?
Heart disease?
Heart murmur?
Hemophilia?
Hepatitis?
High blood pressure or hypertension?
HIV or AIDS?
Hormone therapy?
Ever been hospitalized?
Kidney disease?
Latex or Metal Allergy?
Liver disease, jaundice, or hepatitis?
Nervous disorders?
Pneumonia?
Prolonged bleeding or transfusion?
Radiation treatment?
Rheumatic fever?
Seizures, epilepsy, or neurological disease?
Tonsils or adenoids removed?
Tuberculosis or lung disease?
If any of the above medical questions were answered 'Yes' , please explain:

Patients Under 18

Please be sure and capitalize the first letter of every word when filling out this section. (i,e, Oklahoma City)

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 patient begun puberty?
If patient is a girl, has menstruation begun?
If patient is a boy, has their voice changed or have facial hair?
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:

Notice of Privacy Practices


Personal Health Information Communication via Email:
Be advised, if you select “NO” and we later receive an email from you, we will assume you are now consenting to the use of email.

List the names of people that we can share the patient's information with.
Name:
Relationship to Patient:
Name:
Relationship to Patient:
Name:
Relationship to Patient:
Name:
Relationship to Patient:

Media Release Form

I grant permission to Sky Ortho to use my image (photographs and/or video) for use in Sky Ortho publications including videos, email blasts, recruiting brochures, newsletters, and magazines and to use my image in electronic versions of the same publications or on the Sky Ortho website or other electronic forms of media. I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensations arising from or related to the use of the image.

Please check the paragraph below which is applicable to your present situation:



Signature:
Date: