New Patient Health History Form

Submit your health history form online to your orthodontist today.

Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form and click "submit". Your information will be sent to our office with secure encryption. We will have your information when you arrive for your first appointment.

Patient Information

Name *

First

Middle

Last

Address *

Street Address

City

State

ZIP Code

Home Phone *

Birthdate *

Marital Status *

Sex *

Email

If patient is a minor, parent's / guardian's name

If patient is a minor, name and ages of siblings

Whom may we thank for referring you to our office?

Sports/Hobbies/Musical Instruments

School/Occupation

Current Grade

Nickname

Person Responsible For Account

Same as Above? *

YesNo

Relationship to Patient *

Name *

First

Middle

Last

Address *

Street Address

City

State

ZIP Code

Email

Marital Status *

Home Phone

Birthdate

Have you been at this address longer than 3 years? *

YesNo

Previous Address

Street Address

City

State

ZIP Code

Work Phone

Cell Phone

Social Security #

Employer

Occupation

No. of years employed

Is there an additional responsible party for this account? *

YesNo

Relationship to Patient *

Name *

First

Middle

Last

Address *

Street Address

City

State

ZIP Code

Email

Marital Status *

Have you been at this address longer than 3 years? *

YesNo

Previous Address

Street Address

City

State

ZIP Code

Home Phone

Work Phone

Cell Phone

Social Security #

Employer

Occupation

No. of years employed

Dental Insurance Information

Insured's Name

Insured's Birthdate

Social Security #

Insurance Company

Group No.

Phone

Insurance Co. Address

Insured's Employer

Subscriber/Employee ID #

Do you have dual coverage? *

YesNo

IF YES:Insured's Name

Insured's Birthdate *

Social Security #

Insurance Company

Group No.

Phone

Insurance Co. Address

Insured's Employer

Subscriber/Employee ID #

Emergency Information

Name of nearest relative not living with you *

Relationship *

Cell or Phone *

Complete Address *

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

Please describe concerns *

Has the patient ever been evaluated for or had orthodontic treatment before? *

YesNo

Have there been any injuries to the face, mouth, teeth or chin? *

YesNo

How does the patient feel about wearing orthodontic appliances? *

Have adenoids or tonsils been removed? *

YesNo

Has the patient been informed of any missing or extra permanent teeth? *

YesNo

Has the patient ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)? *

YesNo

Does the patient brush his/her teeth daily? *

YesNo

Floss his/her teeth daily? *

YesNo

Patient's Dentist *

Phone *

Date of Last Visit *

Patient's Physician *

Phone *

Is the patient currently under the care of a physician? *

YesNo

If patient is a minor, has puberty begun? *

YesNoN/A

If yes, when?

Please describe the patient's current physical health *

GoodFairPoor

Do you take or have you taken an osteoporosis medication? *

YesNo

Please list all drugs that the patient is currently taking

Please list all allergies (drugs, foods, other)

Has the patient ever had any of the following medical problems?

Please discuss any medical problems that the patient has had *

Signatures

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in the patient's medical status. I authorize the dental staff to perform the necessary dental services I/my child may need.

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 this office, use services of one or more credit reporting agencies.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.

I understand that at the time of my office visit, my physical signature will be required to confirm the acknowledgements above.

Signature

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

Please check your form to make sure it is complete and press the submit button when you are done. You will see a confirmation page when your form has been successfully submitted. Thank you!

New Patient Health History Form

Patient Information

Person Responsible For Account

Dental Insurance Information

Emergency Information

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

Has the patient ever had any of the following medical problems?

Does/Has the patient have/had any of the following habits?

Signatures