New-Patient-Form | Larson Orthodontics

Preferred Name:

Male Female

Date of Birth:

Additional Gender Notes:

Preferred Email:

Preferred Phone#:

Cell Home Work

If patient is under 18:

School:

Grade:

Sports/Hobbies:

Siblings (Name/Age):

Have any family members previously been treated at our office:

No Yes

Parent’s Information:

Patient Lives with:

Both Parents Dad Mom Other

Parent/Guardian’s Full Name:

Date of Birth:

Address (if different than patient):

Preferred Email:

Preferred Phone#:

Cell Home Work

Parent/Guardian’s Full Name:

Date of Birth:

Address (if different than patient):

Preferred Email:

Preferred Phone#:

Cell Home Work

How did you hear about our office? Check all that apply. Please be specific for future marketing efforts:

Dentist

Friend

Web Search

Social Media

Immediate family member(s) in treatment

Sponsorship/Community Event

Other

Current Dentist:

Date of Last Cleaning (approximate)

List any other dental specialists currently treating the patient:

Chief Concern:

Who is concerned?

Dentist Patient Parents (if under 18)

How does the patient feel about orthodontic treatment?

Any previous orthodontic treatment or consultations?

Dental Insurance: (Fill out all fields – if you provide a copy of your insurance card, still fill out DOB and SSN. If you have Delta Dental please specify what state.)

Primary Policyholder Full Name:

Date of Birth:

Policyholder SSN:

Relationship to Patient:

Insurance Company:

Group#:

ID#:

Secondary Policyholder Full Name:

Date of Birth:

Policyholder SSN:

Relationship to Patient:

Insurance Company:

Group#:

ID#:

Are you in overall good health?

Yes No

Have you had a physical in the last year?

Yes No

Are you currently under the care of a physician or specialist? Yes No

If yes, explain

Has the patient’s physician recommended pre-medication with antibiotics prior to dental appointments?

Yes No

Do you have allergies to any of the following (please list any additional severe allergies under “other”):

Latex

Metals or Acrylics

Antibiotics or drugs

Other

Is there a family history of any of the following conditions?

Severe arthritis

Severe allergies

Extra or missing teeth

Jaw size imbalance or jaw surgery

If so, please explain:

Do you chew or smoke tobacco?

Yes No

Females: Are you currently pregnant?

Yes No

Do you have a history of any of the following conditions: (Check any appropriate boxes and explain below):

ADD/ ADHD

Anemia/bleeding disorder

Arthritis

Asthma

Autism

Birth Defects

Cancer/Tumors

Diabetes

Endocrine/Thyroid Disease

Epilepsy

Fainting

Frequent Headaches/Migraines

Heart Disease

High Blood Pressure

Kidney disease

Liver Disease

Nervous Disorders

Prolonged Bleeding

Respiratory Disease

Additional information:

Please list all medications currently being taken, including prescription, over-the-counter, supplements, and herbal medications.

Medication:

Taken for:

Medication:

Taken for:

Any history of bisphosphonate use? (Zometa, Aredia, Didronel, Fosamax, Actonel, Boniva, Skelid, Didronel)

Yes No

How often do you brush?

Floss?

Are you currently experiencing any of the following?

Sensitive teeth/gums

Difficulty chewing

Soreness in jaw muscles

Broken/chipped teeth

Clicking/locking of jaw joint

Frequent canker sores

Food frequently trapped between teeth

Have you previously experienced any of the following (if so, please explain below)?

Dental trauma

Jaw fractures or cysts

Gum problems (periodontal disease)

Thumb sucking

Fingernail biting

Grinding/Clenching

If yes to any of the above, please explain:

I authorize release of any information regarding my child’s orthodontic treatment to my dentist and dental insurance company. I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my child’s medical or dental health.

Parent/Guardian Signature

Date:

New Patient Form

Medical History

Dental History

Release and Waiver: