Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Date:
Address:
City:
State:
Zip:
Sex:
Age:
Birthdate:
Home Phone:
Cell Phone:
Email:
Referred By:
Primary Dentist:
Dentist Phone:

Responsible Party

Primary Responsible Party

First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
SSN:
Email:
Relationship to Patient:

Secondary Responsible Party

First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
SSN:
Email:
Relationship to Patient:

Dental Insurance Information

Primary Insurance Information

Insured's Name:
Birthdate:
SSN:
Employer Name:
Employer Number:
Insurance Company Name:
Policy Number:
Group Number:
Insurance Company Phone:
Relationship to Patient:
Claims Address:

Secondary Insurance Information

Insured's Name:
Birthdate:
SSN:
Employer Name:
Employer Number:
Insurance Company Name:
Policy Number:
Group Number:
Insurance Company Phone:
Relationship to Patient:
Claims Address:

Emergency Contact

Emergency Contact Person:
Relationship to Patient:
Phone:

Medical and Dental History

For the following questions please mark 'yes' or 'no' if you have or have had any of the following. The answers are for office records only and will be considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation.

Last Dental Visit:
Bad Breath
Bad Taste
Bleeding Gums
Blisters on Lips or Mouth
Burning sensation on tongue
Chew on Side of Mouth
Cigarette, pipe or cigar smoking
Clicking or popping jaw
Dry mouth
Fingernail Biting
Food collection between teeth
Grinding teeth
Gums swollen or tender
Jaw Pain
Mouth breather
Sensitive to hot/cold
How often do you floss?
How often do you Brush?

AIDS
Abnormal Bleeding w/ extractions or surgery
Anemia
Angina/Chest Pain
Anxiety/Nervous problems
Artificial heart valve
Artificial joints
Asthma
Blood disease
Blood transfusion
Cancer/Radiation treatment
Chemical dependency
Circulatory problem
Cirrhosis
Congenital heart lesion
Cortisone treatments
Diabetes
Dialysis
Drug use
Prosthetic replacement
Rheumatic fever
Scarlet fever
Tuberculosis
Emphysema
Epilepsy/Seizure
Fainting/Dizziness
Headaches
Heart murmur
Heart problem
Hemophilia
Hepatitis type
Herpes
High blood pressure
HIV+
Jaundice
Kidney disease
Leukemia
Liver disease
Low blood pressure
Mitral valve prolapse
Nervous problem
Chronic cough for more than 3 weeks
Blood sputum
Unexplained weight loss
Night sweats
Recent travel outside US
Live in concentrated housing with another tuberculosis patient
Other medical conditions not listed?

Women

Are you pregnant?
If patient is a girl, has menstruation begun?

Medications

List any medications you are currently taking:
Pharmacy name:
Pharmacy number:
* Do you or have you ever taken prophylaxis (antibiotics) prior to dental treatment of any kind? If yes, please list and notify the front desk/doctor.

Allergies

Latex
Nickel
Foods, Medications, or other substances? (Please specify):

Office Survey

Please complete a brief office survey:
If treatment is deemed necessary, what is your ideal initial payment?



If Other:
If treatment is deemed necessary, what is your ideal monthly payment?



If Other:

Notice of Privacy Policy

I have reviewed a copy of the Aloha Orthodontics Notice of Privacy Practices. Click here to review
Signature: