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

* 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?
(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?
* Did the patient breastfeed?
* Any difficulty nursing?
* 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?
* For children and teens, has patient reached puberty?
FEMALES: Has menstruation begun? If yes, at what age, month/year?
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 of Parent/Guardian:
* Date:
* Relationship to Patient: