Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Phone:
Cell Phone:
Email:
Social Security Number:
If patient is under 18, please type name(s) of parent(s)/guardian(s):
If patient is under 18, who does the patient live with?
Please list the names of any family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Check any that you'd like to use towards treatment fee:
FSA
HSA
Care Credit
Financial Party Information
What payment option works best for you?
Payment in full with special discount
Interest free financing
How interested are you in having orthodontic treatment?
Very
Only if necessary
Check if the patient is also the person who will be financially responsible for treatment.
Responsible Party 1
First Name:
Middle Initial:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Separated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Address:
City:
State:
Zip:
How long at this address?
Previous address (less than 3 years)?
Email:
Phone:
Cell Phone:
Work Phone:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Responsible Party 2
First Name:
Middle Initial:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Separated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Address:
City:
State:
Zip:
How long at this address?
Previous address (less than 3 years)?
Email:
Phone:
Cell Phone:
Work Phone:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Dental Insurance Information
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Insurance Company Name:
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 Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Emergency Contact Information
Name:
Address:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Phone:
Dental History
Dentist Name:
Checkup Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consult before?
No
Yes
if yes, when?
Has the patient had orthodontic treatment before?
No
Yes
If yes, when?
Does the Patient need to premedicate prior to dental visit?
No
Yes
What is the patient's main orthodontic concern?
Medical History
Please check all health conditions that apply:
Speech Problems/Therapy:
Major Illness:
Operations/Hospitalization:
Medications:
Allergies:
Tooth/Jaw Trauma:
Jaw Joint Pain/Popping:
Prosthetic Heart Valve/Joint Replacement:
Other Medical History:
Significant Dental Treatments:
Tonsils/Adenoids Removed
Finger/Thumb Habit
Are there any special needs you would like us to be aware of?
Pregnant
I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.