Patient Information
First Name:
Last Name:
Nickname:
Birthdate:
Gender (at birth):
Male
Female
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
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Occupation:
Spouse's Name:
Occupation:
Address:
City:
State:
Zip:
Primary Phone:
Email:
Do you have insurance that covers orthodontics?
No
Yes
If so, please name the Insurance Company:
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Subsciber ID:
Social Security Number:
Group #:
Do you have
Secondary
insurance that covers orthodontics?
No
Yes
If so, please name the Insurance Company:
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Subsciber ID:
Social Security Number:
Group #:
Dental History
General Dentist Name:
Has the patient had an orthodontic consult or treatment?
No
Yes
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?
No
Yes
Clench or grind teeth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Frequent headaches?
No
Yes
Injury to face, jaw, teeth, or mouth?
No
Yes
Missing or extra permanent teeth?
No
Yes
Mouth breathing?
No
Yes
Oral habits (thumb or finger sucking, lip or nail biting)?
No
Yes
Pain, tenderness, or noise in either jaw?
No
Yes
Requires premedication (Your dentist requires you to premedicate with antibiotics prior to your dental appointments)?
No
Yes
Snoring?
No
Yes
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?
No
Yes
Asthma?
No
Yes
Take Bisphosphonates (Fosamax, Boniva)?
No
Yes
Bone disorders or loss?
No
Yes
Cancer?
No
Yes
Diabetes?
No
Yes
Heart defect (congenital)?
No
Yes
Heart condition?
No
Yes
Hemophilia?
No
Yes
Hepatitis?
No
Yes
HIV or AIDS?
No
Yes
Latex Allergy?
No
Yes
Nickel Allergy?
No
Yes
Seizures, epilepsy, or neurological disease?
No
Yes
Sleep Apnea?
No
Yes
Tonsils or adenoids removed?
No
Yes
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?
Both parents together
Both parents separately
Mother
Father
School:
If patient is a girl, has menstruation begun?
No
Yes
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.
*
I have reviewed the HIPAA Consent Policy and understand.
Signature
Date