Patient Information: Patients Under 18 Years of Age

First Name:
Middle Initial:
Last Name:
Nickname:
Sex:
Pronoun Preference:
Address:
City:
State:
Zip:
Birthdate:
Age:
Home Phone:
Email:
Cell Phone:
Text Appointment Confirmation:
Do you give us permission to text or call this number to leave a message or voicemail?
School:
Grade:
Sports/Hobbies:
Names & Ages of Siblings:
Whom may we thank for referrring you to our office? Check all that apply.

Responsible Party Information

1. First Name:
Middle Initial:
Last Name:
Address (If different from above):
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
Relationship to Patient:
Birthdate:
Employer:
Years:

2.. First Name:
Middle Initial:
Last Name:
Address (If different from above):
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
Relationship to Patient:
Birthdate:
Employer:
Years:

Dental Insurance Information

1. Subscriber's Name:
Social Security #/ID #:
Subscriber's DOB:
Group #:
Insurance Company:
Insurance Address:
Insurance Phone:

2. Subscriber's Name:
Social Security #/ID #:
Subscriber's DOB:
Group #:
Insurance Company:
Insurance Address:
Insurance Phone:

Emergency Contact Information

Name of nearest relative NOT living with you:
Phone:
Relationship to you:

Medical History

Physician:
Date of Last Visit (month/year):
Phone:
City:
Are you allergic to any medications?
If yes, what?
Have you had any operations?
If yes, what?
Ever been involved in a serious accident?
If yes, please briefly explain the accident:
Have you seen a physician in the last 12 months?
For what reason?
Latex Allergy?
If yes, what is your reaction?
Other allergies?
Please list:
What do you do to relieve symptoms of allergies (medications, nasal spray, etc)?
Please check any of the following conditions that apply to the patient now or in the past:
Do you take medication?
If other, what?
Have you seen any of the following practitioners?
Provider:
Provider:
Provider:
Provider:
Provider:
Provider:
Provider:
Provider:
Provider:

Dental History

General/Pediatric Dentist:
Date of Last Visit (month/year):
City:
Phone:
How many times per day do you brush?
How often do you floss?
Has anyone ever shown you how to properly brush or floss?
Do you argue with your parents about brushing?
Do you need reminders to brush?
Have you ever had a cavity?

Social Concerns

Do you avoid showing your teeth when smiling?
Do you avoid photos?
Do you feel anxious or unsure of yourself?
Do you prefer we NOT discuss jaw structure directly?
Have you ever had a negative reaction (emotionally) to dental treatment?
Do you prefer extra instructions when learning or experiencing something new?

Teeth and Gums

Are you currently in any dental pain?
Have you ever had any teeth removed by a dentist?
Are your teeth sensitive to temperature or pressure?
Do your gums bleed when brushing or flossing?

Jaw Joints

Are your jaw muscles tight in the mornings when you wake up?
Do you notice clicking or popping of your jaw joints?
If yes, is it painful?
Do you have episodes of restricted movements with your jaws (jaws locked open or closed)?
Do you get frequent headaches?
Do you notice ringing in your ears?

Growth & Development

Have you experienced any injuries to your jaws or face?
If yes, what?
Are you still growing taller or growing out of your shoes/clothes?
Have you started your menstral cycle?
If yes, when?
Does late-growth run in your family?
If breast fed, was latching difficult?

Speech

Have you been evaluated by a speech language pathologist?
Provider:
Do you have any speech concerns?
Please detail any information regarding your speech concerns, or what was addressed with your speech language pathologist.

Oral Habits & Eating

Do you clench or grind your teeth during the day?
Do you clench or grind your teeth at night?
Do you chew with your mouth open?
Do you avoid certain foods based on texture?
Are you a loud eater?
Do you avoid hard or chewy food?
Would your eating preferences be considered?
Do you have any other oral habits?
Check all that apply:

Sleep Health and Airway

Do you have difficulty falling or staying asleep?
Do you wake up easily throughout the night?
Do you snore?
Do you gasp or choke at night while sleeping?
Do you frequently feel tired during the day?
Are you an active sleeper (moving a lot or sweating a lot)?
Do you have difficulty breathing through your nose (in general)?
Have you ever been screened for sleep-disordered breathing (ex. obstructive sleep apnea)?
Do you wet the bed at night?

Orthodontic History

Have you ever seen an orthodontist?
Have you ever had orthodontic treatment?
If yes, when:
Which of the following would you like us to emphasize in your initial consultation? Check all that apply.
Do you have any treatment preferences? Check all that apply.

Notice of Privacy Acts Consent Form

I understand that I have certain rights given to me under the Health Insurance Portability and Accountability Act (HIPPA) regarding my protected health information. I understand that by signing this consent form, I authorize you to use and disclose my protected health information for the following:

  • Treatment including that given by all health care providers involved in my care.
  • Obtaining payment from third party payers including insurance companies and other paying parties.
  • The day-to-day health care practices of the orthodontic practice.
I have also been informed that I may request a copy of the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy or the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care options. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

I understand that I may ask that this consent be revoked but I must do so in writing. However, any use or disclosure that occurred prior to the date is not affected.

I attest to the accuracy of this information and acknowledge that it is my responsibility to notify this office of any medical or contact changes; I authorize release of any information to a third party for insurance claims, education, and/or treatment; I understand that a credit bureau check may be obtained where necessary.
Responsible Party:
Relationship to Patient
Signature:
Date: