Welcome to the
Orthodontist!
The benefits of a happy, healthy smile are immeasurable! A beautiful smile is a
wonderful asset.
Please fill out this form completely. The better we communicate, the better we can
care for you. Print This Form, Complete and Bring to Your First
Appointment
About You
Orthodontic Insurance (Primary)
Today's Date
Email Address
Orthodontic Coverage Yes
No
Name:
Last
First
Middle
Mr/Mrs/Ms
Dental Coverage Yes
No
I prefer to be called
Male Female
Insurance Co Name:
Birthdate
/
/
Age:
SS#
Insurance Co Address:
Home Address:
Insurance Co Phone #
( )
City
State: Zip:
Group # (plan, local or policy #)
Single Married Divorced
Widowed Separated
Insured's name:
Relation:
Hm#: ( )
Page/Other# ( )
Insured's birthdate
/
/
Insured's SS#
Wk# ( )
Ext DL#
Insured's Employer:
Employer
Secondary
Insurance
Employer's address
Orthodontic Coverage Yes
No
How long there?
Occupation
Dental Coverage Yes
No
Where & when are best times to
reach you?
Insurance Co Name:
Whom
may we thank for referring you?
Insurance Co Address:
Other family members seen by us?
Insurance Co Phone #
( )
General
dentist:
Group # (plan, local or policy #)
Last visit date:
Insured's name:
Relation:
Spouse Information
Insured's birthdate
/
/
Insured's SS#
His/Her Name:
Insured's Employer:
Employer:
Wk# ( )
Ext: SS#:
In the event of an emergency, is
there someone who lives near you that we should contact?
Birthdate
/
/
His/Her Name:
Relation:
Person Responsible for Account:
Wk# ( )
Hm#: ( )
Wk# ( )
Ext: Hm#: (
)
Medical History
Billing Address:
Physician's Name:
Relation:
SS#
Phone#: ( )
Date of last visit:
Employer:
DL#
Your current health is: Good Fair Poor
Dental History
Are you currently under the care of
a physician? Yes No
What are the main concerns that you
would like orthodontics to accomplish?
Please explain:
Are you taking any prescription /
over the counter medication?
Yes, No
List each one:
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
For Women: Are you taking birth
control pills? Yes No
Do you now or
have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)? Yes No
Are you pregnant? Yes No Week #
Are you nursing? Yes No
Dental History Continued
Medical History Continued
Your current dental health is:
Good Fair Poor
Have you ever had any of the
following diseases or medical problems?
Do you like your smile? Yes No
Y
N
Abnormal bleeding
Y
N
Heart Surgery / Pacemaker
Gums ever bleed? Yes No
Y
N
Anemia/Radiation Treatment
Y
N
Hemophilia
Have you ever had an injury to your
mouth?
Mouth ChinTeeth
Y
N
Artificial Bones/Joints/Valves
Y
N
Hepatitis
Do you have any speech problems? Yes No
Y
N
Asthma / Arthritis
Y
N
High / Low Blood Sugar
Do you generally breathe through
your mouth? Yes
No
Y
N
Blood Transfusion
Y
N
HIV+ / AIDS
If yes,
While awake?
While Asleep? (Circle)
Y
N
Cancer / Chemotherapy
Y
N
Hospitalization for Any Reason
Do you have any extra or permanent
teeth? Yes No
Y
N
Congenital Heart Defect
Y
N
Kidney Problems
Y
N
Diabetes / Tuberculosis (TB)
Y
N
Mitro Valve Prolapse
Y
N
Difficulty Breathing
Y
N
Psychiatric Problems
Are you allergic to any of the following?
Y
N
Drug / Alcohol Abuse
Y
N
Rheumatic / Scarlet Fever
Y
N
Aspirin
Y
N
Dental Anesthetics
Y
N
Penicillin
Y
N
Emphysema / Glaucoma
Y
N
Severe / Frequent Headaches
Y
N
Any Metals / Plastics
Y
N
Erythromycin
Y
N
Tetracycline
Y
N
Epilepsy / Seizures / Fainting
Y
N
Shingles
Y
N
Codeine
Y
N
Latex
Y
N
Other
Y
N
Fever Blisters / Herpes
Y
N
Sinus Problems
Please list any drugs /
materials you may be allergic to:
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:
I 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 or fees and may, at the discretion of the
office, use the services of one or more credit reporting services.
If this office
accepts insurance, I understand that I am responsible for payments of services rendered
and also responsible for paying any co-payment and deductibles that my insurance does not
cover.
Signature
Date
Signature
Date
Our office is committed to meeting or exceeding the standards of infection
control mandated by OSHA, the CDC and the ADA.
OFFICE USE ONLY OFFICE USE ONLY
OFFICE USE ONLY
I verbally reviewed the medical / dental
information above with the patient named herein. Initials:
Date: