Amazing smiles patient form

Patient Contact Information

Date

Patient’s Full Name

Nickname

Patient’s Address

Home/Cell Phone

Cell carrier

City

State

Zip Code

Patient’s Birthday

Age

Male Female

Hobbies

Patient’s Dentist

Patient’s School

Whom May We Thank For Referring You?

Other Family Members Seen By Us

RESPONSIBLE PARTY INFORMATION

Name

Married Single Divorced

Home/Cell Phone

Cell carrier

Home Address

Relationship To Patient

Your Birthday

Cell Phone

Email Address (we do not share these with anyone else)

Your Employer

Social Security #

Your Occupation

Work Phone

Spouse’s Name

Spouse’s Birthday

Spouse’s Employer

Work Phone

Spouse’s Occupation

Social Security #

INSURANCE INFORMATION

PRIMARY ORTHODONTIC INSURANCE

Employee’s Name

Social Security #

Insurance Co. Name

Insured’s Birthday

Relationship To Patient

Insured’s Employer

SECONDARY ORTHODONTIC INSURANCE

Employee’s Name

Social Security #

Insurance Co. Name

Insured’s Birthday

Relationship To Patient

Insured’s Employer

Patient Contact Information

RESPONSIBLE PARTY INFORMATION

INSURANCE INFORMATION

PRIMARY ORTHODONTIC INSURANCE

SECONDARY ORTHODONTIC INSURANCE

HEALTH HISTORY

MEDICAL HISTORY

Please provide a response to all:

DENTAL HISTORY

Please circle if patient has or has had…

Any injuries to:

EMERGENCY CONTACT INFORMATION