NEW PATIENT FORM

PATIENT INFORMATION:

Last:

First:

Middle Initial:

Nickname:

Gender:

MF

Identifies as:

MFThey-Them

Patient Date of Birth:

Home Address:

City:

State:

Zip:

Cell Phone Number:

Email:

Appointment Reminder and treatment Texts ok?

YN

Responsible Party’s Name:

Relation:

Responsible Party DOB:

SSN:

What is the main concern regarding patient’s smile?

Other Parent /Guardian/Spouse Information:

Name:

Relation:

Email:

Cell:

Patient’s Primary Care Physician:

Phone #:

Patient’s Dentist:

Phone #:

Who may we contact in case of an emergency? (Print full name)

Phone #:

Relation:

School Name:

Hobbies/sports:

Date of last physical:

Date of last dental cleaning:

Any pending dental treatment needed that you know of?

YN

Who may we thank for referring you to our office?

Who will be financially responsible for this bill? (Print full name)

Relation:

INSURANCE INFORMATION:

Primary Dental Insurance Company:

Ortho coverage?

YN

Active Policy?

YN

Primary Insured name:

Member ID/SSN:

Group ID:

Policy ID:

Insured DOB:

Secondary Dental Insurance Company:

Ortho coverage?

YN

Active Policy?

YN

Secondary Insured name:

Member ID/SSN:

Group ID:

Policy ID:

Insured DOB:

MEDICAL AND DENTAL QUESTIONNAIRE

Has the patient ever had orthodontic treatment before?

YN

Does the patient brush and floss daily?

YN

Why is the patient seeking Orthodontic treatment?

Please explain any extensive dental work the patient has had before:

Does the patient have regular medical exams?

YN

Is the patient up to date with immunizations?

YN

Has the patient ever been hospitalized?

YN

Has the patient ever had general anesthesia or sedation?

YN

Has the patient ever had bleeding gums?

YN

Is the patient presently undergoing any medical treatment?

YN

If Yes, please list:

Does the patient smoke or use tobacco products?

YN

Is the patient allergic to any medicine?

YN

If Yes, please list:

Has the patient experienced unfavorable reactions from previous care?

YN

If Yes, please list:

Is the patient pregnant?

YN

Condition of patient’s general oral health: (Circle the option that applies):

GoodFairPoor

Does the patient have any of the following concerns: (Check all boxes that apply)

OverbiteCrooked teethJaw painSpeech difficultyBite feels offCrowdingUnderbiteImpacted toothTeeth sticking forwardOpen BiteGingival recessionDiastemaTongue thrust

Does the patient have any history of the following: (Check all boxes that apply)

Mouth breathingJaw constantly lockingTMJ pain / poppingNail bitingTeeth GrindingLip bitingTongue TieTongue thrustJaw ClenchingLip suckingThumb suckingTrouble breathing at night

Is there any sensitivity in the patient’s mouth due to:

ColdHeatChewingSweets

Does the patient have any history of Previous Injury?

YN

Has the patient ever been diagnosed with or had any of the following conditions: (Check all boxes that apply)

ADHDAIDSAlcoholism / Drug AbuseAnemiaAnxietyArthritisAsthmaAutismBacterial EndocarditisBipolar DisorderBladder IssuesBlood Circulation IssuesBrain InjuryBronchitisCancerCardiovascular DiseaseCerebral PalsyChicken PoxCleft Lip / PalateConvulsions / Seizures / EpilepsyDental ExtractionsDental ImplantsDepression

DiabetesDiphtheriaEndocrine GlandsExcessive Bleeding ProblemIssues w/Eyes/Ears/NoseFaintingGastrointestinal-Stomach IssuesGlaucomaGum DiseaseHearing LossHeart Disease / MurmurHemophiliaHepatitisHigh / Low Blood PressureHIVHyperactivityJaundiceKawasaki DiseaseKidney IssuesLeukemiaLiver IssuesMeaslesMumps

Muscle IssuesNervous System DisorderOrgan TransplantOsteoporosisProsthetic Valves / JointsPsychiatric DisorderRadiation TherapyRespiratory IssuesRheumatic FeverScarlet FeverScoliosisSickle CellSinus IssuesSkin / Throat IssuesSpeech TherapySpina BifidaStrokeTetanusTMJ ProblemsTonsils / AdenoidsVenereal DiseaseOther:

ALLERGIES:AnestheticsAspirinBeesCodeineDustIbuprofenLatexNickelPeanutsPenicillinPollenSeasonalShellfishTree nutsOther:

Is the patient currently taking any medication? If yes please list:

Permission is hereby granted to Woodinville Orthodontics to perform any necessary work related to Orthodontic treatment for the patient.

Patient Signature[ If over 18years of age]:

OR

Responsible Party Signature: