PATIENT INFORMATION
Patient Name:
LAST
FIRST
MI
Preferred Name:
Gender:
Male
Female
Non-Binary
Birthdate:
Age:
Home Address:
CITY
STATE
ZIP
Primary Phone Number:
Email:
Occupation:
Employer:
Marital Status:
S
M
D
W
SO
SPOUSE/PARTNER INFORMATION
Name:
LAST
FIRST
MI
Address (If different than patient):
CITY
STATE
ZIP
Primary Phone Number:
Occupation:
Employer:
RESPONSIBLE PARTY FOR ACCOUNT
Name:
LAST
FIRST
MI
Relationship to Patient:
Address:
CITY
STATE
ZIP
Phone Number:
Social Security Number:
Birthdate:
PRIMARY DENTAL INSURANCE
Insurance Co. Name:
Insurance Co. Address:
CITY
STATE
ZIP
Insurance Co. Phone:
Group #:
Member ID #:
Policy Holders Name:
Relationship to Patient:
Policy Holders SSN:
Policy Holders Birthdate:
Employer:
SECONDARY DENTAL INSURANCE
Insurance Co. Name:
Insurance Co. Address:
CITY
STATE
ZIP
Insurance Co. Phone:
Group #:
Member ID #:
Policy Holders Name:
Relationship to Patient:
Policy Holders SSN:
Policy Holders Birthdate:
Employer:
DENTAL HISTORY
General Dentist:
Phone:
What was the date of their last visit:
How did you hear about our practice?
Advertisement
Internet
Family/Friend
Dentist
Other
Whom may we thank for referring you (if applicable)?
What are the main concerns that you would like orthodontics to correct?
Do you like your smile?
Yes
No
Have you visited an orthodontist before?
Yes
No
If yes, date/reason:
Have we treated other family members? If yes, please list their names:
Have
Tonsils
Adenoids
been removed?
Do you or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)
Yes
No
If yes, please describe left/right or both. AM or PM:
Do you have any missing or extra permanent teeth?
Yes
No
Have you ever had injury to the following: (Select all that apply)
Teeth
Jaw
Chin
Please describe injury:
Do they currently or have they ever had any of the following habits: (Check all that apply)
Clenching/Grinding teeth:
Lip Sucking/Biting:
Thumb/Finger Sucking:
Mouth Breathing:
Tongue Thrusting:
Nail Biting:
Chewing/Eating Problem:
Do your gums bleed?
Yes
No
Do you use tobacco products?
Yes
No
MEDICAL HISTORY
Are you currently under a physician’s care?
Yes
No
If yes, explain:
Family Physician:
Phone:
What was the date of their last visit:
Do you have any allergies or sensitivities? (ie medication, latex, nickel, etc)
Yes
No
If yes, explain:
Are you taking any medications at this time?
Yes
No
If yes, explain:
Have you ever had a blood transfusion?
Yes
No
If yes, explain:
WOMEN
Are you pregnant?
Yes
No
Are you nursing?
Yes
No
Are you taking birth control?
Yes
No
Please check if you ever had any of the following:
ADD/ADHD
Cough, Persistent
High Blood Pressure
Stroke
Anemia
Coughing Blood
HIV/AIDS
Swelling of Feet or Ankles
Arthritis, Rheumatism
Diabetes
Kidney Disease
Thyroid Problems
Articial Heart Valves
Epilepsy
Liver Disease
Tonsillitis
Articial Joints
Fainting
Mitral Valve Prolapse
Tuberculosis
Asthma
Glaucoma
Pacemaker
Ulcer
Blood Disease
Headaches
Radiation Treatment
Venereal Disease
Cancer
Heart Murmur
Respiratory Disease
Other
Chemotherapy
Heart Problems
Rheumatic Fever
Circulatory Problems
Hemophilia
Scarlet Fever
Cortisone Treatments
Hepatitis
Shortness of Breath
AUTHORIZATION - PLEASE SIGN & DATE
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 of confidence and it is my responsibility to inform the oce of any changes in my medical status. I hereby authorize the release of any information pertaining to my dental treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the oce. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.
Signature:
Date: