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Request An Appointment

Name * Required
First Last
Selector * Required
- Call
- Email
Call * Required
Email * Required
Date - must be mm/dd/yyyy format
MM slash DD slash YYYY
Time
: HH
MM
AM/PM
Message
Email
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New Patient Forms

PATIENT DETAILS

Full Name * Required
First Last

Patient's Address * Required

Street Address City State ZIP Code

Gender * Required

Home Phone

Date of Birth - must be dd/mm/yyyy format

DD slash MM slash YYYY

Age

Race

Cell Phone

School/Employer

Grade/Position

Work phone

Email * Required

How did you hear about our office * Required

Family members treated in our office

Reason for Consultation * Required

Previous Dentist * Required

Date of last cleaning - must be dd/mm/yyyy 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 ZIP Code

Employer

Work Phone

Date of birth - must be dd/mm/yyyy 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 ZIP Code

Employer

Work Phone

Date of birth - must be dd/mm/yyyy 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
If yes, when?
MM slash DD slash YYYY
Have adenoids been removed?
- Yes
- No
If yes, when?
MM slash DD slash YYYY
Have tonsils been removed?
- Yes
- No
If yes, when?
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 * Required
Relationship to Patient * Required
Date - must be mm/dd/yyyy 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

Δ

CONTACT

253-639-6868

17265 SE WAX ROAD, SUITE 101,

COVINGTON, WA 98042

HOURS

MONDAY
9:00 A.M. - 7:00 P.M.
TUESDAY
9:00 A.M. - 6:00 P.M.
WEDNESDAY
9:00 A.M. -6:00 P.M.
THURSDAY
9:00 A.M. -6:00 P.M.
FRIDAY
9:00 A.M. -6:00 P.M.
SATURDAY
BY APPOINTMENT ONLY

LOCATIONS SERVICED

COVINGTON

KENT

MAPLE VALLEY

BLACK DIAMOND

AUBURN

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