Confidential Patient Information

First Name:
MI:
Last Name:
Nickname:
General Dentist:
Date of Birth:
Age
Gender:
Street Address:
City:
State:
Zip:
Primary Phone:
Primary Contact:
Secondary Phone:
Secondary Contact:
Email:
Employer:
Job Title:

Financial Party Information

First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:

Dental Insurance Information

Please type N/A in any field not applicable

Insurance Company Name:
Subscriber Name (Policyholder):
ID or SS#:
Group Number:
Subscriber DOB:
Policy Holder's Employer:
Insurance Company Phone:

Do you have dual dental coverage?
(If yes, complete information below)

Insurance Company Name:
Subscriber Name (Policyholder):
ID or SS#:
Group Number:
Subscriber DOB:
Policy Holder's Employer:
Insurance Company Phone:

Health History

Has the patient had an orthodontic consult or treatment? If so, when?

Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Allergies/Asthma?
Frequent Nasal Congestion?
Thumb or finger sucking habit?
Sleep Apnea?
Bleeding Disorder?
Heart murmur?
Behavioral Problems?
Epilepsy
Heart disease?
Pregnant?
Frequent Headaches?
Rheumatic Fever?
Hepatitis?
Drug Sensitivities?
Mouth Breather?
Tongue Tie?
Osteoporosis?
Does the patient have any special medical conditions not listed above?
Do you notice clicking or popping in your jaw joint?

Is the patient now under the care of a physician (other than routine)? If so, what is being treated?

Airway and Sleep:
Snores?
Restless Sleep?
Difficulty breathing during sleep?
Daytime Sleepiness?
Daytime Hyperactivity (ADD/ADHD)?
Teeth Grinding?
Bed Wettting?
Acid Reflux?
Chew with mouth open?
Lips apart at rest?
Dark circles under eyes?
By typing my name below, I acknowledge that I have reviewed Dunegan & Cole Orthodontics Privacy Practices. Click here to review
E-Signature:
Date:
Relationship to Patient: