Confidential Patient Information

* First Name:
Middle Initial:
* Last Name:
Nickname:
* Birthdate:
* Gender:
* Address:
* City:
* State:
* Zip:
* Main Phone:
2nd/Cell Phone:
Email:
School and Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Please list the name and birthdate of any siblings:

Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
How did you hear about us?

Financial Party Information

* First Name:
Middle Initial:
* Last Name:
* Birthdate:
Relationship to Patient:
Email:
* Address:
* City:
* State:
* Zip:
* Main Phone:
2nd/Cell Phone:
Social Security #:
If so, please name the Insurance Company:
Employer:
Occupation:
Length of Employment:
Work Phone #:

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID # or Social Security Number:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Do you have dual dental coverage?
(If yes, complete information below)

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID # or Social Security Number:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:

Dental History

Previous Dentist Name:
Date of Last Dental X-rays:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
If so, when?

Please select Yes/No for the following, occurring in the past or present
* Speech problems/therapy?
* Grind or clench teeth?
* Injury to face, jaw, teeth or mouth?
* Discomfort from teeth or gums?
* Pain, tenderness or noise in either jaw?
* Frequent headaches?
* Oral habits (thumb/finger sucking, lip/nail biting, pacifier use)?
* Use fluoride toothpaste?
* Frequent sore throats?
* Brush teeth daily?
* Floss teeth daily?
* Mouth breathing?
* Snores during sleep?
* Requires premedication?
* Any missing or extra permanent teeth?
* Apprehensive about dental care?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of last Physical:
Patient Health:
Address:
City:
State:
Zip:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select YES or No for the Following Questions - Do Not Leave Blank
* Autism
* Developmental Delay
* Rheumatic Fever
* Tuberculosis/Lung Disease
* Pneumonia
* Liver Disease
* Kidney Disease
* Heart Attack/Stroke
* Heart Disease
* Congenital Heart Defect
* Heart Murmur
* Hemophilia
* Hypertension/High Blood Pressure
* Prolonged Bleeding/Transfusion
* Anemia
* HIV/AIDS
* Hepatitis
* Tonsils/Adenoids Removed
* Cancer
* Family History of Cancer
* Received Radiation Treatment
* Growth Problems
* Endocrine Problems
* Hormone Therapy
* Latex/Metal Allergy
* Nervous Disorders
* Bone Disorders/Bone Loss
* Diabetes
* Seizures/Epilepsy
* Handicaps/Disabilities
* Asthma
* Arthritis
* Treated for Emotional Problems
* Ever Been Hospitalized
If any of the above medical questions were answered 'Yes' , please explain: