WELCOME!

We would like to welcome you to our office. Our goal is to help you achieve a beautiful smile and while reaching and maintaining maximum oral health in a warm, courteous, safe and caring environment. Please fill out these forms completely.

Name

Nickname

Birthdate

Age

School

Grade

Home Phone #

Cell Phone #

Home Address

City

State

Zip code

Parent’s Full Name

Mother’s Address (if different than above)

Cell #

Cell Provider

Home#

Employer

Work #

Father’s Address (if different than above)

Cell #

Home#

Employer

Work #

How may we best contact you to make appointments?

Name of person(s) financially responsible for account:

Address (if different from above)

Emergency Contact other than Parent(s) in case we are unable to reach a parent

Name

Relationship

Phone #

Are their any siblings?

Name

Age

Seen by us Y N

Name

Age

Seen by us Y N

Name

Age

Seen by us Y N

Dentist

Physician

Whom may we thank for referring you?

Medical History

Ever had the following medical problems?

Latex Sensitive

Yes No

Precocious puberty

Yes No

Allergies to drugs, substances

Yes No

Delayed Physical Growth and Maturation

Yes No

Allergies

Yes No

Hormone Therapy for growth related issues

Yes No

Heart Murmur

Yes No

Congenital Heart Defect

Yes No

Cancer

Yes No

Convulsions/Epilepsy

Yes No

Diabetes

Yes No

Abnormal Bleeding

Yes No

Rheumatic Fever

Yes No

Hearing Impairment

Yes No

HIV+/AIDS

Yes No

Any Operations

Yes No

Hemophilia

Yes No

Any stays in a hospital

Yes No

Asthma, Airway or Breathing Problems

Yes No

Kidney/Liver Problems

Yes No

Hepatitis

Yes No

Handicaps/Disabilities

Yes No

TB/Lung Disorders

Yes No

Cold Sores/Fever Blisters

Yes No

Blood Transfusion

Yes No

Venereal Disease

Yes No

Mitral Valve Prolapse

Yes No

Diet (special, restricted)

Yes No

Sickle Cell Disease

Yes No

Artificial Joints (hip,etc.)

Yes No

Ulcers/Stomach Disorders

Yes No

Thyroid Problems

Yes No

Chemotherapy, Radiation Treatment

Yes No

Tumors

Yes No

Nervous/Anxious

Yes No

ADD, ADHD, PDD (circle one)

Yes No

Austism, Asperger's Syndrome (circle one)

Yes No

Fainting or Dizzy Spells

Yes No

Sleep Apnea

Yes No

Psychiatric/Psychological Problems

Yes No

Heart Attack/Stroke

Yes No

Pacemaker

Yes No

Glaucoma

Yes No

Emphysema

Yes No

High /Low Blood Pressure (circle one)

Yes No

Severe or frequent headaches

Yes No

Osteoporosis/Osteopenia

Yes No

Please explain any medical problems:

Physical Development (please circle one):

Early

Late

On Time

Percentile Height

Percentile Weight

Adenoids or tonsils been removed?

Y N

Boys - Voice Change

Y N

If yes, when did it change?

Girls — Onset of Menstruation

Y N

if yes, date of onset

Currently under the care of a physician?

Y N

If yes, for what condition?

Have you been a hospital patient during the past two years?

Y N

Women

Are you pregnant?

Y N

Week #

Nursing?

Y N

Taking birth control pills?

Y N

Please list all drugs that are currently being taken and the reason for medication:

Have you ever been treated with medications for osteoporosis, osteopenia, abnormal bone conditions or cancer?

If yes, please list name of medication(s) :(i.e., Fosamax, Actonel, Zometa, Aredia, Boneva, etc.)

Please list all drugs/substances allergic to:

Dental History

Any previous orthodontic consultations or had orthodontic treatment?

Y N

Why did you come to the orthodontist today?

Date of last dental visit?

Full x-rays

Ever had serious/difficult problems associated with previous dental work?

Y N

Experienced early or late tooth eruption?

Play any musical wind instrument?

Y N

Ever had?

Oral Surgery

Yes No

Serious Injury (mouth/head)

Yes No

Periodontal treatment

Yes No

Ever experienced?

Difficulty in chewing

Yes No

Pain (joint, ear, face)

Yes No

Headaches

Yes No

Tired Jaws

Yes No

Problem opening, closing mouth

Yes No

Clicking or popping of jaw

Yes No

Any of the following habits?

Tongue Thrust

Yes No

Thumb/Finger sucking

Yes No

Tooth Grinding

Yes No

Mouth Breather

Yes No

Lip Biting

Yes No

Nail/Pencil biting

Yes No

Nursing Bottle Habits

Yes No

Do you frequently get cold sores, blisters or any other oral lesions?

Y N

Your current dental health is:

Good

Fair

Poor

Do you grind your teeth?

Y N

Do your gums ever bleed?

Y N

Do you like your smile?

Y N

As a courtesy and service to our patients we will provide a “super bill” that you may submit with your claim form for reimbursement from your insurance company. We do not accept assignment of benefits from the insurance companies.

It is important to attend appointments. Please understand that a last minute cancellation or “no show” does not allow us enough time to accommodate another patient. Because the time we allot is valuable, kindly give our office 24 hours notice if you must cancel an appointment. We reserve the right to charge a $150.00 for every 30 minutes for any appointment not cancelled within 24 hours.

I understand that I am responsible for all costs of orthodontic treatment and that in the event of a default of one of the responsible parties/parents, I am entirely responsible for all costs of orthodontic treatment and will pay them in a timely manner.

Signature of Responsible Person(s)

Date:

Signature of Responsible Person(s)

Date:

Please initial to acknowledge that you have received the Notice of Privacy Practices