Date:
Confidential Patient Information
Patient’s Name:
First
Middle
Last
Patient’s Nickname:
Nickname
Gender:
Male
Female
Address:
Street
City
State
Zip
Email:
DOB:
School:
Whom may we thank for referring you to our office?:
Siblings:
DOB:
Gender:
Male
Female
Siblings:
DOB:
Gender:
Male
Female
Siblings:
DOB:
Gender:
Male
Female
Siblings:
DOB:
Gender:
Male
Female
Are there any other family members you would like us to see for a complimentary orthodontic evaluation?
Yes
No
Responsible Party Information
Name:
First
Middle
Last
Social Security:
DOB:
Relationship to Patient:
Mailing Address:
Street
City
State
Zip
How long at this address:
Previous Address(if less than 3 yrs):
Street
City
State
Zip
Email:
OK to contact you by email?
Yes
No
Home phone:
Work Phone:
Cell phone:
Employer:
Occupation:
No. Years Employed:
(If Dental Insurance) Company Name:
Marital Status (please circle one):
S
M
Sep
Div
W
Spouse’s Name:
First
Middle
Last
Social Security:
DOB:
Relationship to Patient:
Work Phone:
Cell Phone:
Email:
Employer:
Occupation:
No. Years Employed:
(If Dental Insurance) Company Name:
Emergency Contact Information
Name:
Relationship:
Phone:
I understand that where appropriate, credit bureau reports will be obtained.
Signature
(Parent’s signature if minor)
Updates (date & initial):