To the Orthodontist

The benefits of a happy, healthy smile are immeasurable! A beautiful smile is a wonderful asset.

Please fill out this from completely. The better we communicate, the better we can care for you.

1 About You

E-mail Address:

Last Name:

First Name:

I prefer to be called:

Sex: MaleFemale



SS #:

Home Address:





Hm #:

Cell/Other #:

Wk #:

Ext #:



Employer's Address:

How long there?


Where & when are best times to reach you?

Whom may we Thank for referring you?

Other family members seen by us:

General Dentist:

Last Visit Date:

2 Spouse Information

His / Her Name:


Wk #:


SS #:



Person Responsible for Account:

Wk #:

Ext #:

Hm #:

Billing Address #:


SS #:


DL #:

3 Orthodontic Insurance


Orthodontic Coverage: YesNo

Dental Coverage: YesNo

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone:

Group # (Plan, Local or Policy #):

Insured's Name:


Insured's Birthday:

Insured's ID #:

Insured's Employer:

In the event of an emergency, is there someone who lives near you that we should contact?

His / Her Name:


Wk #:

Hm #:

4 Medical History

Do you have a personal physician? YesNo

Physician's Name:

Phone #:

Date of last visit:

5 Medical History Continued

Your current physical health is: GoodFairPoor

Are you currently under the care of a physician? YesNo

Your explain:

Are you taking any prescription / over the counter drugs? YesNo

Please list each one:

For Women: Are you using any prescribed method of birth control? YesNo

Are you pregnant? YesNo

Week #:

Are you nursing? YesNo

Have you ever had any of the following disease or medical problems?

Abnormal Bleeding YesNo

Anemia YesNo

Artificial Bones/Joints/Valves YesNo

Asthma / Arthritis YesNo

Blood Transfusion YesNo

Cancer / Chemotherapy YesNo

Congenital Heart Defect YesNo

Diabetes YesNo

Difficulty Breathing YesNo

Drug / Alcohol Abuse YesNo

Emphysema YesNo

Epiledpsy/Seizures/Fainting YesNo

Fever Blisters / Herpes YesNo

Glaucoma YesNo

Heart Attack / Stroke YesNo

Heart Murmur YesNo

Heart Surgery / Pacemaker YesNo

Hemophilia YesNo

Hepatitis YesNo

High / Low Blood Pressure YesNo


Hospitalized for Any Reason YesNo

Kidney Problems YesNo

Mitral Valve Prolapse YesNo

Phychiatric Problems YesNo

Radiation Treatment YesNo

Rheumatic / Scarlet Fever YesNo

Shingles YesNo

Sickle Cell Disease / Traits YesNo

Sinus Problems YesNo

Tuberculosis (TB) YesNo

Ulcers / Colitis YesNo

Venereal Disease YesNo

Please list any serious medical condition(s) that you have ever had:

Are you allergic to any of the following?

Aspirin YesNo

Any Metals/Plastics YesNo

Codeine YesNo

Dental Anesthetics YesNo

Erythromycin YesNo

Latex YesNo

Penicillin YesNo

Tetracycline YesNo

Other YesNo

6 Dental History

What are the main concerns that you would like orhodontics to accomplish?

Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD)? YesNo

Your current dental health is: GoodFairPoor

Do you like your smile? YesNo

Gums ever bleed? YesNo

Have you ever had an injury to your MouthTeethChin

Do you generally breath through your mouth? YesNo

If yes, please press circle: While awake?While Asleep?

Do you have any missing or extra permanent teeth? YesNo

Have you ever taken Fosamax, or any other bisphonate? YesNo

Have you ever taken Phen-Fen? YesNo

Do you smoke or use tabacco in any form? YesNo

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.



Thank you for filling out this form completely.

This office reserves the right to verify the credit status of potential patients and / or parents of patients prior to extending credit for treatment fees and may, at the discreation of the office, use the services of one or more reporting services.



If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office.



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