Date:
Account Number:
(Office Use Only)
Patient Information
Patient Name:
Extension (Jr., I, II, etc.):
Address:
City:
State:
Zip:
Home Phone:
Business Phone:
Cell Phone:
Email:
Date of Birth:
Age:
Gender:
Female
Male
Referred By:
Family Dentist:
List all individuals we may speak to regarding the patient’s account/treatment:
Parent/Guardian (If Applicable)
(Complete as needed. Leave blank if patient is an adult.)
Name:
Mom
Dad
Stepparent
Guardian
Address:
City:
PA:
Date of Birth:
SSN:
Cell:
Name:
Mom
Dad
Stepparent
Guardian
Address:
City:
PA:
Date of Birth:
SSN:
Cell:
Name:
Mom
Dad
Stepparent
Guardian
Address:
City:
PA:
Date of Birth:
SSN:
Cell:
Insurance Information
Primary Dental Insurance Carrier:
Member ID:
Policy Holder’s Name:
Relationship to Patient:
Date of Birth:
SSN:
Secondary Dental Insurance Carrier:
Member ID:
Policy Holder’s Name:
Relationship to Patient:
Date of Birth:
SSN:
Name and Ages of Other Children in Family (if applicable):
Health History
Is the patient in good health?
Yes
No
Puberty onset?
Yes
No
Date:
Diabetes
Prolonged Bleeding
Nervous Disorders
Endocrine Problems
Epilepsy
Bone Disorders
Pneumonia
Fainting/Dizziness
Kidney/Liver,
Heart Trouble/Murmur
Rheumatic Fever
Frequent colds/ear infections
Anemia
Asthma
Tuberculosis
Autism
Other:
Drug/Allergy Reactions:
Does the patient take anti-inflammatory meds (e.g., Advil, Ibuprofen, Celebrex) or bisphosphonates?
Yes
No
Have tonsils/adenoids been removed?
Yes
No
Date:
Snoring?
Yes
No
Mouth breather?
Yes
No
Dental History
Any injuries to the face/mouth/teeth?
Yes
No
Date:
Explain:
Head/Neck Pain
Jaw clicking/popping
Ear Pain
Headaches
Jaw locking
Thumb/finger/pacifier sucking habit?
Yes
No
Nail biting?
Yes
No
Until what age?
Speech problems?
Yes
No
Explain:
Missing or extra permanent teeth?
Yes
No
Does the patient play sports?
Musical instrument?
Previously consulted an orthodontist?
Yes
No
Date:
Who:
What is your main concern?
Consent & Authorization
I consent to all diagnostic and orthodontic treatment procedures performed by the doctors or clinical staff. I authorize the release of relevant health/treatment information to other providers and authorize payment of any dental benefits to Signature Orthodontics of Pittsburgh for services rendered.
Signature
Relationship to Patient:
Date: