Patient Information

First Name:
Last Name:
Nickname:
Birthdate:
Gender (at birth):
Address:
City:
State:
Zip:

Please list the names of any family currently in the practice:
List any sports, hobbies, or musical instruments played (ages 12 and below):
Whom may we thank for referring you to our practice?

Responsible Party Information

First Name:
Last Name:
Relationship to Patient:
Occupation:
Spouse's Name:
Occupation:
Address:
City:
State:
Zip:
Primary Phone:
Email:

Do you have insurance that covers orthodontics?
If so, please name the Insurance Company:
Policy Holder's Name:
Relationship to Patient:
Birthdate:
Subsciber ID:
Social Security Number:
Group #:
Do you have Secondary insurance that covers orthodontics?
If so, please name the Insurance Company:
Policy Holder's Name:
Relationship to Patient:
Birthdate:
Subsciber ID:
Social Security Number:
Group #:

Dental History

General Dentist Name:
Has the patient had an orthodontic consult or treatment? If so, when?
What is the patient's main orthodontic concern?
Please briefly describe what is most important to you/your family in choosing an orthodontist:

Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Apprehensive about dental care?
Clench or grind teeth?
Discomfort from teeth or gums?
Frequent headaches?
Injury to face, jaw, teeth, or mouth?
Missing or extra permanent teeth?
Mouth breathing?
Oral habits (thumb or finger sucking, lip or nail biting)?
Pain, tenderness, or noise in either jaw?
Requires premedication (Your dentist requires you to premedicate with antibiotics prior to your dental appointments)?
Snoring?

Medical History

Physician/Pediatrician Name:
Please list any medications currently being taken by the patient (include non-prescription):
Please list any other drug allergies or sensitivities that the patient may have:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
ADD/ADHD?
Asthma?
Take Bisphosphonates (Fosamax, Boniva)?
Bone disorders or loss?
Cancer?
Diabetes?
Heart defect (congenital)?
Heart condition?
Hemophilia?
Hepatitis?
HIV or AIDS?
Latex Allergy?
Nickel Allergy?
Seizures, epilepsy, or neurological disease?
Sleep Apnea?
Tonsils or adenoids removed?
Any other medical conditions you feel we should be aware of?

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Who does the patient live with?
School:
If patient is a girl, has menstruation begun? If so, when?

HIPAA Consent

For all appointments following the first exam, we will remind you via both text and email. (If you have a different preference at any time, please let us know.)
Total Orthodontics is required by federal law to maintain the privacy of individuals and provide individuals a copy of the Total Orthodontics HIPAA Consent Policy with the notice of our legal duties and privacy practices with respect to health information.
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