PATIENT INFORMATION


Patients Name Last
First
Middle

Address
Street

City
State
Zip

Phone Birth date S.S.N. E-mail address
Work Phone Cell Phone    
   


Marital Status
Married Single Separated Divorced Widowed
Children (Names and ages please)  
Whom can we thank for referring you to our office? 

RESPONSIBLE PARTY INFORMATION


Check this box if patient is Responsible Party  
Name Marital Status

Last
First
Middle
Residence
Street

City
State
Zip
Mailing Address
Street

City
State
Zip
Home Phone Work Phone  
Social Security # Birth date Relationship to Patient

Employer Occupation

Spouse's Name 

Last
First
Middle

Employer Occupation  
 
Social Security # Birth Date Work Phone
     


EMERGENCY CONTACT INFORMATION

Contact Name Phone #
Address

Street
City
State
Zip
Relationship to patient


ORTHODONTIC INSURANCE INFORMATION


Insured's Name Insured's Social Security #
Insured's Employer

Insurance Company Group Number Local Number

Insurance Company Address
Insurance Phone Number

MEDICAL HISTORY


Family Physician
Phone Number
Date of Last Visit

YES NO     YES NO  
Are you taking any medication?
If yes, specify
 Have you had any major operations?
Are you allergic to any medications?
If yes, specify
 Have you ever been involved in a serious accident?
Do you have a history of a major illness?
If yes, specify
      
Have you ever had any of the following diseases or medical problems
YES NO     YES NO  
Abnormal Bleeding / Hemophilia Hepatitis / Liver Problems
Anemia Herpes
Arthritis High Blood Pressure
Asthma or Hayfever HIV + / AIDS
Bone Disorders Kidney Problems
Congenital Heart Defect Nervous Disorders
Diabetes Pneumonia
Dizziness Prolonged Bleeding
Epilepsy Radiation / Chemotherapy
Gastrointestinal Disorders Rheumatic Fever
Heart Problems Tuberculosis
Heart Murmur Tumor or Cancer
Are there any medical conditions we have not discussed that you feel we should be aware of?

PATIENT DENTAL HISTORY


General Dentist
Date of Last Visit
Dentist Phone Number
What Concerns you most about your teeth?
Please explain in detail specific orthodontic concerns:

  YES NO
Are you presently in any dental pain?
Have you ever experienced any unfavorable reaction to dentistry?
Have you ever lost or chipped any teeth?
Have there been any injuries to face, mouth or teeth?
Is any part of your mouth sensitive to temperature or pressure?
Do your gums bleed when you brush?
Do you have any type of thumb or tongue habit?
Are you a mouth breather?
Have you ever seen an orthodontist?
Has anyone in the family received orthodontic treatment?
How did they feel about the result ?
What is your attitude toward orthodontic treatment ?
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
Are you aware of your jaw clicking or popping?
Are you aware of clenching your teeth during the day?
Have you ever been told that you grind your teeth?
Do you have "tension" headaches?
Have you ever experienced chronic ringing in your ears ?
Are you aware some appointments will be during school / work hours?
     
Please list any additional concerns or comments:

I hereby authorize payment of the group insurance benefits(otherwise payable to me) directly to this office. I understand that I am responsible for all costs for orthodontic treatment whether or not paid by insurance. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered to my insurance company. I authorize the use of this signature on all insurance submissions, whether filed manually or electronically. 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 that it is my responsibility to inform this office of any changes in my or my child's medical status. I authorize the dental staff to perform any necessary dental services that I, or my child, may need during diagnosis and treatment, with my informed consent. This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment. I further agree to pay all finance charges, collection costs, attorney's fees and any other cost that may be incurred to enforce collection of any outstanding balance and authorize credit bureau reports to be obtained for collection purposes.

Initials of Patient(if over 18) or Legal Guardian | Date: 7/30/2010