Blacker Orthodontics

PLEASE FILL OUT THIS FORM.

1. PATIENT INFORMATION

Name First

Last

Nick Name

Sex

Phone

Birthday

Age

Address

City

Zip

2. RESPONSIBLE PARTY INFORMATION

FATHER/GUARDIAN or SELF (if Adult Patient) INFO

Name First

Last

Address

City

State

Zip

Home #

Cell

Work

Birthday

Driver’s License #

S.S.#

How long at this address?

Would you like text message appointment reminders?

Yes No

MOTHER/SPOUSE INFORMATION

Name First

Last

Address

City

State

Zip

Home #

Cell

Work

Birthday

Driver’s License #

S.S.#

How long at this address?

Text Message?

Yes No

Are the Patient’s Parents Married?

Yes No

EMPLOYER INFORMATION

Employer Name

Employer Address

Employer City

State

Zip

# of Years Employed

Occupation

Orthodontic Coverage?

Yes No

Insurance Company Name

Insurance Address

Insurance City

State

Zip

Insurance Phone

Ext

Group #

Subscriber ID #

EMPLOYER INFORMATION

Employer Name

Employer Address

Employer City

State

Zip

# of Years Employed

Occupation

Orthodontic Coverage?

Yes No

Insurance Company Name

Insurance Address

Insurance City

State

Zip

Insurance Phone

Ext

Group #

Subscriber ID #

3. OTHER INFORMATION

Who is the Responsible Party?

Other Children

Date of Birth

DOB

Dentist Name

Who may we thank for referring you to our office?

School Name

Grade

Emergency Contact Name

Relationship to Patient

Phone#

PATIENT NAME

4. MEDICAL INFORMATION

YES NO

Yes No

Is Patient Under Medical Care

Yes No

Heart Disease

Yes No

Respiratory Disease

Yes No

Blood Disease

Yes No

Thyroid Disease

Yes No

Kidney Disease

Yes No

HIV/AIDS

Yes No

Intestinal Disease

Yes No

Bone Disease

Yes No

Epilepsy

Yes No

Endocrine Disease

Yes No

Liver Disease

Yes No

Prolonged Bleeding

YES NO

Yes No

History of Fainting or Dizziness

Yes No

Nervous/Emotional Problems

Yes No

Does the Patient Smoke

Yes No

Drug Addiction

Yes No

Measles/Mumps/Chicken Pox

Yes No

High/Low Blood Pressure

Yes No

Is Height and Weight Normal

Yes No

Has Patient Reached Puberty

Yes No

Heart Murmur

Yes No

Heart Valve Problems

Yes No

Hepatitis

Yes No

Anemia

Yes No

Any Allergies

YES NO

Yes No

Latex Allergy

Yes No

Nickel (Metal) Allergy

Yes No

Tuberculosis

Yes No

Diabetes

Yes No

Chemical Dependence

Yes No

Hemophilia

Yes No

Asthma or Hay Fever

Yes No

Rheumatism or Arthritis

Yes No

Tumors or Cancer

Yes No

Radiation Therapy

Please List any Problems Not Mentioned that we Should Know About

List any Medications the Patient is Taking

Is the Patient Pregnant?

Yes No

5. DENTAL HISTORY

YES NO

Yes No

Has the Patient Seen a General Dentist in the Last Year

Yes No

Any Pain, Clicking or Discomfort in or Near the Ears (Jaw Joints)

Yes No

Has the Mouth, Face or Teeth Been Injured by a Fall or Accident

Yes No

Have you Been Informed of Missing or Extra Permanent Teeth

Yes No

Are You Aware of Any “Gum” Problems

Yes No

Have the Patient’s Tonsils or Adenoids Been Removed

Yes No

Thumb or Finger Sucking (Past Age 5)

Yes No

Mouth Breathing

YES NO

Yes No

Fingernail Biting

Yes No

Speech Problem or Speech Therapy

Yes No

Clenching or Grinding Teeth

Yes No

Tongue Thrusting

Yes No

Has the Patient Been Examined by an Orthodontist Before

If Yes, When

Yes No

Have Other Member of the Family had Orthodontic Treatment

Yes No

Are You Happy About Your Teeth and Smile

What would you like to improve about your teeth and smile?

How do you feel about wearing braces or Invisalign?

Any concerns?

I understand that the information I have given on this form is accurate and that I am obligated to inform Dr. Blacker immediately if any information changes in the future. I understand that where appropriate, credit reports (”soft inquiry”) may be obtained.

Signature of Patient or Parent/Guardian if patient is a minor

Date

PLEASE FILL OUT THIS FORM.

1. PATIENT INFORMATION

2. RESPONSIBLE PARTY INFORMATION

FATHER/GUARDIAN or SELF (if Adult Patient) INFO

MOTHER/SPOUSE INFORMATION

EMPLOYER INFORMATION

EMPLOYER INFORMATION

3. OTHER INFORMATION

PATIENT NAME

4. MEDICAL INFORMATION

YES NO

YES NO

YES NO

5. DENTAL HISTORY

YES NO

YES NO

THANKS FOR THE INFORMATION!

TEMPE6200 S. McClintock, #101 • Tempe, AZ 85283 • (480) 839-6262

CHANDLER3200 S. Alma School, #201 • Chandler, AZ 85248 • (480) 917-7977