About You

First Name:
Middle Initial:
Last Name:
I Prefer to be Called:
Birth Date:
Age:
Sex:
Social Security #:
Address:
City:
State:
Zip:
Cell Phone:
Email:
Preferred appt reminder:
Occupation:
Years at Occupation:
Employer:
Do you have any children or pets?
If Yes, what are their names/ages:
Please list any special interest (Sports/Hobbies/etc.):
Marital Status:

Spouse's/Partner's Name:
Birthdate:
Age:
Cell #:
Occupation/yrs:
Employer:

Whom may we thank for referring/getting you to our office?
How else did you hear about us? (check all that apply)
What main concerns do you want to address with orthodontic treatment?
If needed, would you be interested in starting treatment on the same day as the consultation?
If No, explain:
Have you been evaluated or had orthodontic treatment before?
If Yes, explain:
Please list names/relationship of any other family/Friends seen in our office:

Dental Health Information

Is patient experiencing any dental problems?
Does the patient brush and floss each day?
Has all dental work completed at this time?
If no, please explain:
Name of General Dentist:
Phone:
Date of last dental visit:
Does patient have or have they had any of the following conditions or problems? (Check those that apply)

Medical Health Information

Are you taking any medication at this time?
If yes, Details:
Is patient presently under a physicans care?
If yes, Details:
Does patient have or have they had any of the following diseases or conditions? (Check those that apply)
Does patient have any disease, condition, or problem not listed that you think we should know about? Please explain:
Who should we contact in case of an emergency?
Phone:

Dental Insurance Information

Primary Policy Holder Name:
SSN:
Date of Birth:
Primary Insurance Company Name:
Subscriber ID:
Group/Plan#:
Relationship to Patient:
Ortho Coverage/Amount if known:

Secondary Policy Holder Name:
SSN:
Date of Birth:
Secondary Insurance Company Name:
Subscriber ID:
Group/Plan#:
Relationship to Patient:
Ortho Coverage/Amount if known:
Do you participate in a flex plan or have a Health Savings Account?
If Yes, Details:
I acknowledge that the above information is correct. I will notify Dr. Tim of any changes that occur after this date. I hereby authorize Dr. Tim and his team to perform an initial orthodontic evaluation/examination.

Signature:
Date: