Become a Patient — Covington, WA New Patient Form New Patient FormPatient DetailsFirst NameLast NamePatient AddressAddress Line 1Address Line 2CityStateZip CodeEmailDate of BirthGender- Select -MaleFemaleOtherRace- Select -American IndianAsianAfrican AmericanHispanic or LatinoPacific IslanderWhiteOtherSchool / EmployerGrade / PositionAdditional Patient DetailsHow did you hear about our office?Family members treated in our officeReason for Consultation?Previous DentistDate of last cleaningHas the patient been examined by an orthodontist before? Yes NoGuardian #1 / Insurance InformationGuardian #1 Self Spouse Father Mother Step Parent OtherGuardian #1 OtherGuardian's First NameGuardian's Last NameGuardian's AddressAddress Line 1Address Line 2CityStateZip CodeEmailDate of BirthSocial Security NumberEmployerInsurance Information (If Applicable)Insurance CompanyPhone NumberSubscriber / Member IDGuardian #2 / Insurance InformationIs there a second guardian and / or additional insurance to add? Yes NoGuardian #2 Self Spouse Father Mother Step Parent OtherGuardian #2 OtherGuardian's First NameGuardian's Last NameGuardian's AddressAddress Line 1Address Line 2CityStateZip CodeEmailDate of BirthSocial Security NumberEmployerOrthodontic Insurance (If Applicable)Insurance CompanyPhone NumberSubscriber / Member IDSleep / Airway IssuesDoes the patient tend to be a mouthbreather? Yes NoDoes the patient snore at night? Yes NoDoes the patient seem rested in the morning? Yes NoIs the patient often sleepy during the day? Yes NoHas the patient seen an Ear, Nose & Throat Specialist? Yes NoHas the patient seen an Ear, Nose & Throat Specialist? Yes NoDental / Medical HistoryPlease check if the patient has a history of the following medical conditions:Acid Reflux Yes NoADHD/ADD Yes NoAIDS/HIV Yes NoAnemia Yes NoArthritis Yes NoAsthma Yes NoAutism Yes NoBone Disorders Yes NoCancer Yes NoChest Pain Yes NoCerebral Palsy Yes NoChronic Neck Pain Yes NoClicking of Jaw Yes NoJaw Pain Yes NoCold Sores/Herpes Yes NoDiabetes Yes NoDown Syndrome Yes NoEndocrine Problems Yes NoEmotional Disorders Yes NoEpilepsy Yes NoHeadaches Yes NoHeart Condition Yes NoHepatitis Yes NoEar Pain Yes NoImmune Problems Yes NoKidney Problems Yes NoLow Blood Pressure Yes NoMuscular Disorders Yes NoNervous Disorders Yes NoOrgan Transplant Yes NoOsteoporosis Yes NoPainful Chewing Yes NoPeriodontal Problems Yes NoProlonged Bleeding Yes NoRheumatic Fever Yes NoScoliosis Yes NoSeizures Yes NoSinus Problems Yes NoTMJ Problems Yes NoTuberculosis Yes NoDental QuestionsDo your gums bleed when you brush? Yes NoIs the patient seeing any other dental specialists? Yes NoWhich Specialists?Any dental restorations needing to be completed? Yes NoWhich restorations?Have there ever been any injuries to the face, mouth or chin? Yes NoWhich Injuries?Have you ever lost or chipped any teeth? Yes NoWhich Teeth/Tooth?Do you have any pain or soreness around your face, neck or back? Yes NoWhich Soreness?Is any part of your mouth sensitive to temperature or pressure? Yes NoWhich Sensitivities?Is the patient currently pregnant? Yes NoIf yes, when?Have adenoids been removed? Yes NoIf yes, when?Have tonsils been removed? Yes NoIf yes, when?Currently taking any medications? Yes NoWhich medications?Are antibiotics necessary prior to treatment? Yes NoList Here:Allergies? Yes NoWhich allergies?Any diseases or problems not mentioned above? Yes NoList Here:HabitsPlease check if the patient has, or ever had, any of the following habits?Cheek, tongue or lip biting Yes NoClenching Teeth Yes NoFingernail Biting Yes NoGrinding Teeth Yes NoTongue Sucking Yes NoThumb Sucking Yes NoTongue Thrusting Yes NoSigned 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/SignatureRelationship to PatientDateIf 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 statementSubmit Patient Form
