Patient Information
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Main Phone:
Birthdate is not in correct format (mm/dd/yyyy)
Birthdate:
Patient likes to be called:
Referred by:
Hobbies and Interests:
If a student, School and Grade:
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
1st Responsible Party Information
First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Self
Mother
Father
Grandparent
Guardian
Spouse
Stepfather
Stepmother
Other
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
If Married, Spouse's Name:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Email:
Employer:
Occupation:
2nd Responsible Party Information
First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Self
Mother
Father
Grandparent
Guardian
Spouse
Stepfather
Stepmother
Other
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
If Married, Spouse's Name:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Email:
Employer:
Occupation:
* If there are 2 responsible parties
(in different households):
With whom does the patient primarily reside?
If there is a court order regarding Insurance/please explain:
Dental Insurance Information
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Birthdate:
Policy Holder's Employer:
Insurance Company Name:
SS# or Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Birthdate:
Policy Holder's Employer:
Insurance Company Name:
SS# or Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Medical History
Is patient in good health?
No
Yes
Has he/she been treated by a physician in the last 2 years?
No
Yes
Is he/she taking any medications now? If yes, please list below.
No
Yes
Does he/she suffer from any allergies? If yes, please list below.
No
Yes
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Diabetes?
No
Yes
Arthritis?
No
Yes
Hepatitis?
No
Yes
Tuberculosis?
No
Yes
Autism
No
Yes
Asthma?
No
Yes
Nervous disorders?
No
Yes
Epilepsy?
No
Yes
Kidney disease?
No
Yes
Sensory disorder?
No
Yes
Prolonged bleeding?
No
Yes
Heart murmur?
No
Yes
Brain injury?
No
Yes
Heart trouble?
No
Yes
Learning_Disability
No
Yes
Rheumatic fever?
No
Yes
Tonsillitis
No
Yes
Anemia?
No
Yes
Other:
Dental History
(This information will aid in our office communication and instructions during treatment)
Please select 'Yes' or 'No' if there is a history of any of the following. Cannot be blank.
Jaw joint popping?
No
Yes
Clench or grind teeth?
No
Yes
Injury to head/neck/jaw?
No
Yes
Previously treated TMJ?
No
Yes
Noise/pain in jaw or ears?
No
Yes
Mouth breather?
No
Yes
Missing teeth?
No
Yes
*
Oral habits (thumb or finger sucking, lip or nail biting)?
No
Yes
Year stopped:
Uncomfortable bite?
No
Yes
Frequent headaches?
No
Yes
Extra teeth?
No
Yes
Have others in the family had a similar condition or received orthodontic treatment?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Please select 'Yes' if the patient has had any of the TMJ conditions listed below either now or in the past. Cannot be blank.
Have you had a TMJ screening?
No
Yes
Do you have a history of jaw joint problems?
No
Yes
Has patient had any previous orthodontic treatment or consultations?
No
Yes
Names and ages of brothers and sisters:
Last Dental Visit:
Dentist Name:
Any specific problem you would like us to fix?
I attest that the above information is true and accurate and authorize (if applicable) Dr. Holt’s office to bill insurance for treatment. I acknowledge receipt of the office’s
Notice of Privacy Practices
. It is also available at www.BracesByHolt.com or posted in the office.
E-Signature:
Relationship to patient:
Date: