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PATIENT DETAILS
Full Name
*
First
Last
Patient's Address
*
Street Address
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Gender
*
Required
Female
Male
Home Phone
Date of Birth
Date Format: DD slash MM slash YYYY
Age
Race
Race
American Indian
Asian
African American
Hispanic or Latino
Pacific Islander
White
Other
Cell Phone
School/Employer
Grade/Position
Work phone
Email
*
How did you hear about our office
*
Family members treated in our office
Reason for Consultation
*
Previous Dentist
*
Date of last cleaning
Date Format: DD slash MM slash YYYY
Has the patient been examined by an orthodontist before?
Yes
No
GUARDIAN #1 / INSURANCE INFORMATION
Self
Spouse
Father
Mother
Step Parent
Guardian's Full Name
First
Last
Home Phone
Address
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer
Work Phone
Date of birth
Date Format: DD slash MM slash YYYY
Social Security Number
Cell Phone
Guardian's E-Mail
INSURANCE (IF APPLICABLE):
Company Name
Phone
Subscriber/Member ID
GUARDIAN #2 / INSURANCE INFORMATION
Is there a second guardian and / or additional insurance to add?
Yes
No
Self
Spouse
Father
Mother
Step Parent
Guardian's Full Name
First
Last
Home Phone
Address
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer
Work Phone
Date of birth
Date Format: DD slash MM slash YYYY
Social Security Number
Cell Phone
Guardian's E-Mail
ORTHODONTIC INSURANCE (IF APPLICABLE):
Company Name
Phone
Subscriber/Member ID
SLEEP / AIRWAY ISSUES
Does the patient tend to be a mouthbreather?
Yes
No
Does the patient snore at night?
Yes
No
Does the patient seem rested in the morning?
Yes
No
Is the patient often sleepy during the day?
Yes
No
Has the patient seen an Ear, Nose & Throat Specialist?
Yes
No
Is the patient using a sleep apnea device?
Yes
No
DENTAL/MEDICAL HISTORY
Please check if the patient has a history of the following medical conditions:
Acid Reflux
Yes
No
ADHD/ADD
Yes
No
AIDS/HIV
Yes
No
Anemia
Yes
No
Arthritis
Yes
No
Asthma
Yes
No
Autism
Yes
No
Bone Disorders
Yes
No
Cancer
Yes
No
Chest Pain
Yes
No
Cerebral Palsy
Yes
No
Chronic Neck Pain
Yes
No
Clicking of Jaw
Yes
No
Jaw Pain
Yes
No
Cold Sores/Herpes
Yes
No
Diabetes
Yes
No
Down Syndrome
Yes
No
Endocrine Problems
Yes
No
Emotional Disorders
Yes
No
Epilepsy
Yes
No
Headaches
Yes
No
Heart Condition
Yes
No
Hepatitis
Yes
No
Ear Pain
Yes
No
Immune Problems
Yes
No
Kidney Problems
Yes
No
Low Blood Pressure
Yes
No
Muscular Disorders
Yes
No
Nervous Disorders
Yes
No
Organ Transplant
Yes
No
Osteoporosis
Yes
No
Painful Chewing
Yes
No
Periodontal Problems
Yes
No
Prolonged Bleeding
Yes
No
Rheumatic Fever
Yes
No
Scoliosis
Yes
No
Seizures
Yes
No
Sinus Problems
Yes
No
TMJ Problems
Yes
No
Tuberculosis
Yes
No
Do your gums bleed when you brush?
Yes
No
Is the patient seeing any other dental specialists?
Yes
No
Untitled
Any dental restorations needing to be completed?
Yes
No
Untitled
Have there ever been any injuries to the face, mouth or chin?
Yes
No
Untitled
Have you ever lost or chipped any teeth?
Yes
No
Untitled
Do you have any pain or soreness around your face, neck or back?
Yes
No
Untitled
Is any part of your mouth sensitive to temperature or pressure?
Yes
No
Untitled
Is the patient currently pregnant?
Yes
No
Date Format: MM slash DD slash YYYY
Have adenoids been removed?
Yes
No
Date Format: MM slash DD slash YYYY
Have tonsils been removed?
Yes
No
Date Format: MM slash DD slash YYYY
Currently taking any medications?
Yes
No
Untitled
Are antibiotics necessary prior to treatment?
Yes
No
Untitled
Allergies?
Yes
No
Untitled
Any diseases or problems not mentioned above?
Yes
No
Untitled
Please check if the patient has, or ever had, any of the following habits?
Cheek, tongue or lip biting
Yes
No
Clenching Teeth
Yes
No
Fingernail Biting
Yes
No
Grinding Teeth
Yes
No
Tongue Sucking
Yes
No
Thumb Sucking
Yes
No
Tongue Thrusting
Yes
No
SIGNED CONSENT
I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status.I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate orthodontic treatment on the above-named patient.I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.
Typed Name/Signature
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Relationship to Patient
*
Date
Date Format: MM slash DD slash YYYY
If someone other than the parent(s) or guardian(s) listed above will be bringing the patient to appointments, please list here:
By submitting this form you agree to the above mentioned consent statement
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