Patient Information and Health History

Patient's First Name:
Patient's Middle Initial:
Patient's Last Name:
Patient's Preferred Name:
Height:
Weight:
Date of Birth:
Age:
Gender:
Patient's Mailing Address:
City:
State:
Zip Code:
Patient's School:
Grade:
Patient's Hobbies/Interests
Who may we thank for referring you to our office?
How did you hear about our office?

Responsible Party Information

Primary Responsible Party
First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Address:
City:
State:
Zip Code:
Date of Birth:
SSN:
Employer:
Occupation:
Cell Phone:
Alternate Phone:
Email:
Preferred Method of Contact:
Primary Responsible Party's Spouse
First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Address:
City:
State:
Zip Code:
Date of Birth:
SSN:
Employer:
Occupation:
Cell Phone:
Alternate Phone:
Email:
Preferred Method of Contact:
Secondary Responsible Party
First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Address:
City:
State:
Zip:
Date of Birth:
SSN:
Employer:
Occupation:
Cell Phone:
Alternate Phone:
Email:
Preferred Method of Contact:
Secondary Responsible Party's Spouse
First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Address:
City:
State:
Zip:
Date of Birth:
SSN:
Employer:
Occupation:
Cell Phone:
Alternate Phone:
Email:
Preferred Method of Contact:

Insurance Information

Primary Dental Insurance Company:
Dental Insurance Phone:
Group/Plan Number:
Primary Policy Holder's Full Name:
Policy Holder's ID#:
Policy Holder's Date of Birth:
Secondary Dental Insurance Company:
Dental Insurance Phone:
Group/Plan Number:
Secondary Policy Holder's Full Name:
Policy Holder's ID#:
Policy Holder's Date of Birth:

Dental History

Dentist Name:
Last Dental Visit:
Dentist's Concerns:
Any prior trauma/injury to face/mouth? If yes, please explain:
Any history of jaw problems (TMJ/TMD)? If yes, please explain:
Do you have any cavities or gum problems that need to be treated? If yes, please explain:
Are you currently in orthodontic treatment? If yes, who is your orthodontist?
Have you visited an orthodontist before?
Have other family members received orthodontic treatment?
What are your chief concerns?
Are there any esthetic or psycho-social concerns (i.e. teasing, self-esteem, etc.)?

Medical History

Physician Name:
Describe overall health:
Do you have a medical, psychiatric, physical, blood-borne disease or other health condition that required past or ongoing medical treatment? If yes, please explain:
Do you have any history of bleeding problems? If yes, please explain:
Do you take any over-the-counter or prescription medications? If so, please explain:
Do you have any allergies to medications, food, metal or environmental substances? If so, please explain:
Are you pregnant or is there a chance you are pregnant?
Do you smoke or chew tobacco?
Insurance: To avoid a misunderstanding regarding dental insurance, we wish the persons responsible to know that all professional services rendered are charged directly to them and that they are personally responsible for the total professional fee. We submit insurance as a courtesy to our patients, but is in no way a guarantee of payment from the insurance company.
Confidentiality: All information contained on this form will remain strictly confidential. I understand that the information I have provided is correct to the best of my knowledge, that it will be held in the strictest confidence and it is my responsibilty to inform this office of any changes in my medial status.
Consent to Examination and Treatment: I am choosing to be examined and treated at iSmile Orthodontics. I understand that treatment will consist of diagnostic digitial x-rays and photos. My signature below signifies that I understand the above statements and consent to examinations and treatment by the doctor and by the doctor's staff under his/her direct supervision and instruction.
Signature: