Patient Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Gender:
Social Security #:
Nickname (if applicable):
Email:
Cell Phone:
Main Phone:
Address:
City:
State:
Zip:

If patient is a minor, who does the patient live with?
Employer?
School?
Whom may we thank for referring you?
Please let us know other family members seen by Dr. Kay Daniel?

Dental / Medical History

Dentist Name:
Last Dental Visit:
Is there still work to be done from last dental check up? If yes, what?
Chief dental / orthodontics complaint?
Does the patient have:
Pain / clicking in the jaw joint?
A bite that feels uncomfortable or unusual?
Any teeth injured due to an accident?
If yes, please explain:
The following habits are of interest. Please list age the habit was broken:
Thumb Sucking
Grinding Teeth
Lip biting or sucking
Finger Sucking
Clenching Teeth
Tongue thrusting

Responsible Party Information

Marital Status:
Mother's Information
First Name:
Middle Initial:
Last Name:
Social Security Number:
Address:
City:
State:
Zip:
Main Phone:
Email:
Cell Phone:
Employer:
Work Phone:
Father's Information
First Name:
Middle Initial:
Last Name:
Social Security Number:
Address:
City:
State:
Zip:
Main Phone:
Email:
Cell Phone:
Employer:
Work Phone:
*If the child's guardian is not the natural parent, please give relationship:

Insurance Information

Policy Holder's Name:
Relationship to Patient:
Insured's Date of Birth:
SS#:
Policy Holder's Employer:
Subscriber ID:
Insurance Company Name:
Insurance Phone:

Orthodontic History

Has the patient had an orthodontic consult?
Has the patient had an orthodontic treatment?
If yes to either, date?
Doctor?
Physician Name:
Is the patient pregnant or possibly pregnant
Is the patient allergic to Latex?
Is the patient allergic to medication?
If so, what?
Has the patient ever had (Please check all that apply)
Anemia?
Arthritis?
Asthma?
Birth Defects?
Blood Disease?
Bone Disorders?
Cold Sores?
Diabetes?
Endocrine Problems?
Epilepsy?
Head / Face Injury?
Hearing Disorder?
Heart disease?
Heart murmur?
Hepatitis?
Herpes?
HIV or AIDS?
Kidney disease?
Lung Disease?
Mitral Valve Prolapse?
Oral Ulcers?
Previous Surgery?
Rheumatic fever?
Thyroid Problems?
Has the patient ever been diagnosed with any other medical / behavioral / mental condition?
ADD / ADHD?
Autism Spectrum?
Anxiety?
Behavioral Disorder?
Depression / Bi-Polar Disorder?
Emotional Disorder?
Other / Comments
If the patient has been under the care of a physician during the last two years for anything other than routine exams, please explain?
Present drugs or medication?

Respitory History

Does the patient have: (Please check all that apply)

Allergies: Other:
Breathes through mouth:
Snore when sleeping:
Frequent colds:
Frequent stuffy nose:
Frequent sore throat / tonsillitis:
Difficulties chewing / swallowing:
Received medical treatment from an allergist or ear, nose, and throat specialist?
If yes, when: By Whom:
Nasal Surgery?
Tonsils Removed?
Adenoids Removed?
AUTHORIZATION & RELEASE
I certify the above information is correct and complete. I understand that providing incorrect or incomplete information can be dangerous to this patient’s health. I agree to be responsible for payment of all services rendered including what is billed to my insurance company. I authorize my insurance company to pay benefits directly to Dr. Daniel’s office. I understand information will be communicated with anyone who accompanies this patient to appointments. I also authorize Dr. Daniel and her staff to perform any form of treatment, medication, or therapy regarding this patient.
Signature (Patient / Parent / Guardian):
Relationship to Patient:
By typing my name above I am electronically signing this form.