Confidential Patient Information

First Name:

MI:

Last Name:

Nickname:

General Dentist:

Date of Birth:

Age

Gender:

Street Address:

City:

State:

Zip:

What are the patient's interests (i.e. sports, hobbies, or musical instruments)?

If patient is a minor, who does the patient live with?

Financial Party Information

Check if the patient is also the person who will be financially responsible for treatment.

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip:

Main Phone:

Email:

Employer:

Job Title:

Secondary Responsible Party

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip:

Main Phone:

Email:

Employer:

Job Title:

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?

NoYes (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? NoYes 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.

Does the patient have any special medical conditions not listed above?

Did the patient breastfeed? NoYes

Any difficulty nursing? NoYes

Do you notice clicking or popping in your jaw joint? NoYes

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

For children and teens, has patient reached puberty? NoYes

FEMALES: Has menstruation begun? NoYes If yes, at what age, month/year?

Airway and Sleep: