The benefits of a happy, healthy smile are immeasurable!
Our goal is to help you reach and maintain optimal oral health.
Please fill out this form completely. The better we communicate, The better we can care for you.

About You

Name:Last

First

MR MRS MS DR

I prefer to be called:

Male Female

Birthdate:

Age:

SS#:

Adult's Home #:

Home Address:

City

State

Zip

How long at this address:

Previous Address (If less than three years):

City

State

Zip

Single MarriedDivorced WidowedSeparated

Hm #:

Cell / Other #:

Wk #:

Ext:

DL #:

Employer:

Employer’s Address:

City

State

Zip

Where & When are best times to reach you?

E-mail Address:

Whom may we thank for referring you?

Other family members seen by us:

Present Dentist:

Responsible Party

Mother FatherStep MotherGuardian

Name:

Birthday:

Address:

City:

State:

Do you have legal custody of this child?

Yes No

Wk #:

Ext:

Hm #:

Cell #:

SS #:

Email:

Employer:

How Long at Current Job:

Job Title:

Dental Insurance

Primary

Orthodontic Coverage:

Yes No

Dental Coverage:

Yes No

Insurance Member ID:

Insurance Co. Name:

Insurance Co. Address:

City

State

Zip

Insurance Co. Phone #:

Group #:

Insured’s Name:

Relation:

Insured’s Birthdate:

Insured’s SS#:

Insured’s Employer:

Dental Insurance

Secondary

Orthodontic Coverage:

Yes No

Dental Coverage:

Yes No

Insurance Member ID:

Insurance Co. Name:

Insurance Co. Address:

City

State

Zip

Insurance Co. Phone #:

Group #:

Insured’s Name:

Relation:

Insured’s Birthdate:

Insured’s SS#:

Insured’s Employer:

I understand where appropriate, credit bureau reports may be obtained.

Spouse Information

His/Her Name:

Employer:

Work #:

Ext:

Birthdate:

Age:

SS #:

Emergency Contact

His/Her Name:

Work #:

Ext:

Medical History

Do you have a personal physician?

Yes No

Physician’s Name:

Phone #:

Date of last visit:

Your current physical health is:

Good Fair Poor

Are you currently under the care of a physician?

Yes No

Please explain:

Do you smoke or use tobacco in any other form:

Yes No

Have you had any metal rods, pins or implants?

Yes No

Are you taking any prescription / over-the-counter drugs?

Yes No

Please list each one:

Have you ever taken Phen-Fen?

Also known as Redux or Pondimin.

Yes No

If so, when?

Are you pregnant?

Yes No

Week #:

Are you nursing?

Yes No

Have you ever had any of the following diseases or medical problems

Abnormal Bleeding / Hemophilia

Y N

Herpes / Fever Blisters

Y N

AIDS

Y N

High Blood Pressure

Y N

Alcohol / Drugs

Y N

HIV

Y N

Anemia

Y N

Hospitalized for Any Reason

Y N

Arthritis

Y N

Kidney Problems

Y N

Artificial Bones / Joints / Valves

Y N

Liver Disease

Y N

Asthma

Y N

Low Blood Pressure

Y N

Blood Transfusion

Y N

Lupus

Y N

Cancer / Chemotherapy

Y N

Mitral Valve Prolapse

Y N

Colitis

Y N

Pacemaker

Y N

Congenital Heart Defect

Y N

Psychiatric Problems

Y N

Diabetes

Y N

Radiation Treatment

Y N

Difficulty Breathing

Y N

Rheumatic / Scarlet Fever

Y N

Emphysema

Y N

Seizures

Y N

Epilepsy

Y N

Shingles

Y N

Fainting Spells

Y N

Sickle Cell Disease / Traits

Y N

Frequent Headaches

Y N

Sinus Problems

Y N

Glaucoma

Y N

Stroke

Y N

Hay Fever

Y N

Thyroid Problems

Y N

Heart Attack / Surgery

Y N

Tuberculosis (TB)

Y N

Heart Murmur

Y N

Ulcers

Y N

Hepatitis

Y N

Venereal Disease

Y N

Please list any other serious medical condition(s) that you have ever had.

Dental History

What are the main concerns that you would like orthodontics to accomplish?

Have you ever had or been evaluated for orthodontic Treatment?

Yes No

Have you ever had a serious / difficult problem associated with any previous dental work?

Yes No

Do you now or have you ever experienced pain / discomfort in your jaw point (TMJ / TMD)?

Yes No

Your current dental health is:

Good Fair Poor

Have you ever had an injury to your:

Mouth Teeth Chin

Do you have any speech problems?

Do you generally breathe through your mouth?

Yes No

If yes, please circle:

While Awake? While Asleep?

Do you have any missing or extra permanent teeth?

Yes No

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 that it is my responsibility to inform this office of any changes in my medical status. I authorize the staff to perform any necessary services that I may need during diagnosis and treatment, with my informed consent.

Signature:

Date:

Name of the person signing

Allergies

Are you allergic to any of the following?

Aspirin

Y N

Erythromycin

Y N

Penicillin

Y N

Codeine

Y N

Jewelry / Metals

Y N

Tetracycline

Y N

Dental Anesthetics

Y N

Latex

Y N

Other

Y N

Please list any other drugs / materials that you are allergic to:

Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

Acknowledgement of Receipt of Notice of Privacy Practices

Saylor & Murphy Orthodontics

* You May Refuse to Sign This Acknowledgment*

I have received a copy of this office’s Notice of Privacy Practices.

Print Name:

Signature:

Date:

Right to Revoke:

I have the right at any time to revoke this Acknowledgement for any reason. I have the right to sign this portionat a later time/date of my choice to revoke my Acknowledgment.

Signature:

Date:

Name of the person signing

The benefits of a happy, healthy smile are immeasurable!Our goal is to help you reach and maintain optimal oral health.Please fill out this form completely. The better we communicate, The better we can care for you.

About You

Responsible Party

Dental Insurance

Primary

Dental Insurance

Secondary

I understand where appropriate, credit bureau reports may be obtained.

Spouse Information

Emergency Contact

Medical History

Dental History

Allergies

Saylor & Murphy Orthodontics

* You May Refuse to Sign This Acknowledgment*

I have received a copy of this office’s Notice of Privacy Practices.

Right to Revoke:

The benefits of a happy, healthy smile are immeasurable!
Our goal is to help you reach and maintain optimal oral health.
Please fill out this form completely. The better we communicate, The better we can care for you.