spielberg-ortho Orthodontics

A beautiful smile is a wonderful asset. Please fill out this form completely.

The better we communicate, the better we can care for you.

About You

Today’s Date:

Name: Last

First

M F

Birthdate:

Age:

SS#:

Home Address:

City

State

Zip

Single Married Divorced Widowed Separated

Hm #:

Cell #:

Wk #:

DL #:

E-Mail Address:

Employer:

Employer’s Address:

City

State

Zip

How long there?

Occupation:

When are best times to reach you?

Whom may we thank for referring you?

Other family members seen by us:

General Dentist:

Previous Present (Please circle)

Date of last visit:

Orthodontic Insurance

Primary

Orthodontic Coverage:

Y N

Dental Coverage:

Y N

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #:

Group # (Plan, Local or Policy #):

Insured’s Name:

Relation:

Insured’s Birthdate:

Insured’s ID #:

Insured’s Employer:

Secondary

Orthodontic Coverage:

Y N

Dental Coverage:

Y N

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #:

Group # (Plan, Local or Policy #):

Insured’s Name:

Relation:

Insured’s Birthdate:

Insured’s ID #:

Insured’s Employer:

Spouse Information

His/Her Name:

Employer:

Work #:

Ext:

Birthdate:

SS #:

In the event of an emergency, whom should we contact?

His/Her Name:

Relationship:

Wk #:

Hm #:

Person Responsible for Account:

Wk #:

Hm #:

Billing Address:

Relation:

SS #:

Employer:

DL #:

Medical History

Do you currently have a personal physician?

Yes No

Physician’s Name:

Ph #:

Date of last visit:

Your current physical health is:

Good Fair Poor

Medical History Cont.

Are you currently under the care of a physician?

Yes No

Please explain:

Are you taking any prescriptions/over-the-counter drugs?

Yes No

Please list each one:

WOMEN: Are you using a prescribed method of birth control?

Yes No

Are you pregnant?

Yes No

Week

Are you nursing?

Yes No

Have you ever had any of the following diseases or medical problems?

Yes No

Abnormal Bleeding

Yes No

Heart Surgery/ Pacemaker

Yes No

Anemia

Yes No

Hemophilia

Yes No

Artificial Bones / Joints / Valves

Yes No

Hepatitis

Yes No

Arthritis

Yes No

High / Low Blood Pressure

Yes No

Asthma

Yes No

HIV+ / AIDS

Yes No

Blood Transfusion

Yes No

Hospitalized for Any Reason

Yes No

Cancer / Chemotherapy

Yes No

Kidney Problems

Yes No

Congenital Heart Defect

Yes No

Mitral Valve Prolapse

Yes No

Diabetes

Yes No

Psychiatric Problems

Yes No

Difficulty Breathing

Yes No

Radiation Treatment

Yes No

Drug / Alcohol Abuse

Yes No

Rheumatic / Scarlet Fever

Yes No

Emphysema

Yes No

Shingles

Yes No

Epilepsy / Seizures / Fainting

Yes No

Sickle Cell Disease / Traits

Yes No

Fever Blisters / Herpes

Yes No

Sinus Problems

Yes No

Frequent / Severe Headaches

Yes No

Stroke

Yes No

Glaucoma

Yes No

Tuberculosis (TB)

Yes No

Heart Attack

Yes No

Ulcers / Colitis

Yes No

Heart Murmur

Yes No

Venereal Disease

Please list any serious medical condition(s) that you have ever had:

Are you allergic to any of the following:

Yes No

Aspirin

Yes No

Dental Anesthetics

Yes No

Penicillin

Yes No

Codeine

Yes No

Erythromycin

Yes No

Tetracycline

Yes No

Metals / Plastics

Yes No

Latex

Yes No

Other

Please list any other drugs that you are allergic to:

Dental History

What would you like orthodontics to accomplish?

Have you ever had or been evaluated for orthodontic treatment?

Yes No

Have you ever had a serious/difficult problem associated with any previous dental work

Yes No

Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?

Yes No

Your current dental health is:

Good Fair Poor

Do you like your smile?

Yes No

Do your gums ever bleed?

Yes No

Have you ever had an injury to your:

Mouth Teeth Chin

Indicate any speech problems:

Do you breathe through your mouth?

While Awake While Asleep

Do you have any missing or extra permanent teeth?

Yes No

Have you ever taken Fosamax or any other bisphosphonate?

Yes No

Have you ever taken Phen-Fen?

Yes No

Do you smoke or use tobacco in any form?

Yes No

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 confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

Signature

Date:

Thank you for filling out this form completely.

This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services.

Signature

Date:

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office.

Signature

Date:

About You

Orthodontic Insurance

Primary

Secondary

Spouse Information

In the event of an emergency, whom should we contact?

Medical History

Medical History Cont.

Have you ever had any of the following diseases or medical problems?

Are you allergic to any of the following:

Dental History

Thank you for filling out this form completely.

Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.