ORTHODONTIC REGISTRATION
& HISTORY
(PLEASE PRINT)
13385 Folsom Blvd.
Suite 600
Folsom, CA 95630
916 985-8420
1621 Oak Ave
Suite A
Davis, CA 95616
530 750-9504
Date
Home Phone
Cell
PATIENT INFORMATION
Patient Name
E- Mail
Address
City
State
Zip
Sex
M
F
Age
Birthdate
Whom may we thank for referring you?
In case of emergency, who should be notifed?
Phone
RESPONSIBLE PARTY
Person Responsible for Account
Single
Married
Widowed
Separated
Divorced
Relation to Patient
Birthdate
Soc. Sec. #
Address (if different from patient’s)
Phone
City
State
Zip
Employed by
Occupation
Business Address
Business Phone
Insurance Company
Subscriber
Phone Contact #
Group#
Names of other dependents covered under this plan
ADDITIONAL INSURANCE
Is patient covered by additional insurance?
Yes
No
Subscriber
Relation to Patient
Birthdate
Address (if different from patient’s)
Phone
City
State
Zip
Subscriber Employed by
Business Phone
Insurance Company
Soc. Sec. #
Subscriber #
Phone Contact #
Group #
Names of other dependents covered under this plan
ASSIGNMENT AND RELEASE
I, the undersigned, certify that I (or my dependent) have insurance coverage with
Name of Insurance Company(ies)
and assign directly to Dr. Kelleher all insurance benefts, if any, otherwise payable to me for services rendered. I understand that I am fnancially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefts. I authorize the use of this signature on all insurance submissions.
Responsible Party Signature
Relationship
Date
Patient Name
Birthdate
Male
Female
ORTHODONTIC QUESTIONAIRE
Please help us with answering the following questions:
1. Is there anything specific that you’d like orthodontic treatment to accomplish?
Yes
No
If so, please explain:
2. Has there been any pain, clicking or popping in the jaw joint?
Yes
No
3. Any speech therapy or speech problems?
Yes
No
4. Any injuries to the teeth, face, or head?
Yes
No
5. Is breathing normal through the nose, rather than mouth only?
Yes
No
6. Any missing permanent teeth ?
Yes
No
7. Any extra permanent teeth?
Yes
No
8. Are you aware that some appointments could infringe upon school or work time?
Yes
No
9. Has there been any other orthodontic treatment provided or other consultations?
Yes
No
10. Would wearing braces create much in the way of self consciousness?
Yes
No
11. Are other children of the household currently in orthodontic treatment with this office?
Yes
No
12. How often do you floss?
x / Week
Brush?
x / Day
13. Any sensitivity to hot, cold, biting?
14. Any habits such as thumb sucking, clenching or lip biting, past or present?
Yes
No
15. General or Pediatric Dentist
Address
16. Where does your child, who’s receiving treatment, go to school?
MEDICAL HISTORY
Check any of the following you(r) (child) now have or have had in the past:
Allergies
Cortisone Treatments
Hormonal Therapy
Rheumatic Fever
Anemia
Persistent Cough
High Blood Pressure
Scarlet Fever
Arthritis
Coughing Blood
HIV/AIDS
Shortness of Breath
Artificial Heart Valves
Diabetes
Jaw Pain
Skin Rash
Artificial Joints
Epilepsy
Kidney Disease
Stroke
Asthma
Fainting
Liver Disease
Swelling of Feet/Ankles
Birth Control Medicines
Glaucoma
Mitral Valve Prolapse
Thyroid Problems
Back Problems
Headaches
Nursing
Tobacco Habit
Blood Disease
Heart Murmur
Pacemeaker
Tonsillitis
Cancer
Heart Problems
Pregnant
Tuberculosis
Chemical Deficiency
Hemophilia
Radiation Treatment
Ulcer
Chemotherapy
Hepatitis
Respiratory Disease
Venereal Disease
Circulatory Problems
Physician’s Name
Last Visit Date
Any snoring or sleep apnea?
Yes
No
Tiredness even though enough sleep hours
Yes
No
Have you ever had a blood transfusion?
Yes
No
Ever had any serious illnesses or operations?
Medications you are taking:
Allergies:
Aspirin
Penicillin
Latex
Sulfa
Other
The above information is accurate and complete to the best of my knowledge. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I may have made in completing this form.
Signature
Date