I prefer to be called:
Social Security Number
Please select one of the following
Work Phone Number
Whom may we thank for referring you?
Last Visit Date
Insurance Co. Name
Insurance Co. Address
Insurance Co. Phone Number
Policy ID Number
Policy Group Number (Plan, Local or Policy #)
Insured's First Name
Insured’s Last Name
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following?
What are the main concerns that you would like orthodontics to accomplish?
Have you ever had or been evaluated for orthodontic treatment?
Have you ever had a serious/difficult problem associated with any previous dental work?
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?
Your current dental heatth is:
Do you like your smile?
Do your gums ever bleed?
Check the following you've had an injury to:
Do you have any speech problems?
Do you generally breathe through your mouth?
If yes, please check:
Do you have any missing of extra permanent teeth?
Have you ever taken Fosamax, or any other bisphosphonate?
Have you ever taken Phen-Fen?
Do you smoke or use tobacco in any form?
Please check each box to show you understand each statement: *
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes to my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of the office, use the services of one or more credit reporting services.
If this office accepts insurance, I understand that I am responsible for payment of services tendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directty to this office.
Electronic Signature: *
Date of Completion of Form *