About You

Today’s Date:

E-Mail Address:

Name:
  Last First MI
I prefer to be called: Male Female
Birthdate: / / Age:    SS #:
Home Address: APT/Condo #
City: State: Zip:
How long have you lived at this address?
Rent or Own?
Single Widowed Married Divorced Seperated
Home#: ( ) Cell#: ( )
Work#: ( )     Ext:  
Employer:
Employer’s Address:

Occupation:

How long there?
Where & when are the best times to reach you?
Whom may we Thank for referring you?
Other family members seen by us:

General Dentist:

    

Last Visit Date:

    
       


Spouse Information

His/Her Name:

Employer:
Work#: ( )     Ext:     SS #:
Birthdate: / /
Person Responsible for Account:
Work#: ( )   Ext:  
Home#: ( )
Billing Address: APT/Condo #
City: State: Zip:
Relation: SS#:
Employer:   DL#:
       


Orthodontic Insurance
Primary      

Orthodontic Coverage?

 Yes No  

Insurance Co. Name:

   

Insurance Co. Address:

  

Insurance Co. Phone#:

( )

Group# (Plan, Local, or Policy #):

    

Insured’s Name:

    

Relationship to Patient:

   
Insured’s Birthdate: / /   SS#:

Insured’s Employer:

   
Secondary      

Orthodontic Coverage?

 Yes No  

Insurance Co. Name:

   

Insurance Co. Address:

  

Insurance Co. Phone#:

( )
Group# (Plan, Local, or Policy #):

Insured’s Name:

    

Relationship to Patient:

   
Insured’s Birthdate: / /   SS#:

Insured’s Employer:

   

In the event of an emergency, is there someone who lives near you that we should contact?

His/Her Name:

Relation:
Work#: ( )   Home#: ( )


Medical History

Do you have a personal Physician?  Yes No

Physician’s Name:

    

Phone#: ( )  

Date of last visit:
Your current physical health is: Good Fair Poor

Are you currently under the care of a physician?  Yes No
Please Explain:

Are you taking any prescription/over-the-counter drugs? Yes No
Please list each one:

For Women: Are you taking birth control pills? Yes No
Are you pregnant? Yes No  Week#:
Are you nursing? Yes No    
Have you ever had any of the following diseases or medical conditions?
Y N Abnormal Bleeding Y N Hemophilia
Y N Heart Surgery/Pacemaker Y N Asthma/Arthritis
Y N Anemia/Radiation Treatment Y N Hepatitis
Y N Artificial Bones/Joints/Valves Y N Blood Transfusion
Y N High/Low Blood Pressure Y N HIV+AIDS
Y N Hospitalized for Any Reason Y N Cancer/Chemotherapy
Y N Severe/Frequent Headaches Y N Congenital Heart Defect
Y N Diabetes/Tuberculosis (TB) Y N Kidney Problems
Y N Rheumatic/Scarlet Fever Y N Mitral Valve Prolapse
Y N Epilepsy/Seizures/Fainting Y N Psychiatric Problems
Y N Difficulty Breathing Y N Drug/Alcohol Abuse
Y N Emphysema/Glaucoma Y N Shingles
Y N Fever Blisters/Herpes Y N Sinus Problems
Y N Heart Attack/Stroke Y N Ulcers/Colitis
Y N Heart Murmur Y N Venereal Disease
Please list any serious medical condition(s) that you have ever had:

Are you allergic to the following?

Y N

Aspirin

Y N

Erythromycin

 

 
Y N

Latex

 Y N

Penicillin

  

 
Y N

Codeine

Y N

Tetracycline

  

 
Y N Dental Anesthetics Y N Other    
Y N Any Metals/Plastics    
Please list any other drugs/materials that you are allergic to:
       


Dental History
What are the main concerns that you would like orthodontic treatment to address?

Have you ever been evaluated or had orthodontic treatment before?
Yes No
Have you ever had a serious/difficult problem associated with any previous dental work? Yes No
Have you ever had any pain/tenderness 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
Do you have any speech problems? Yes No
Do you generally breathe through your mouth? Yes No
If Yes: While Awake While Asleep

Do you have any missing or extra permanent teeth? Yes No
       
Please read the information below. Your signature will be required when you arrive at our office to show you unsderstand these terms.

I understand that the information that I have given is correct to the best of my knowledge. I also understand that this information will be held in the strictest of 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.


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.


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.


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