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.
I prefer to be called:
How long there?
Where & when are best times to reach you?
Whom may we Thank for referring you?
Other family members seen by us:
Last Visit Date:
His / Her Name:
Person Responsible for Account:
Billing Address #:
Orthodontic Coverage: YesNo
Dental Coverage: YesNo
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone:
Group # (Plan, Local or Policy #):
Insured's ID #:
Do you have a personal physician? YesNo
Date of last visit:
Your current physical health is: GoodFairPoor
Are you currently under the care of a physician? YesNo
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
Are you nursing? YesNo
Abnormal Bleeding YesNo
Artificial Bones/Joints/Valves YesNo
Asthma / Arthritis YesNo
Blood Transfusion YesNo
Cancer / Chemotherapy YesNo
Congenital Heart Defect YesNo
Difficulty Breathing YesNo
Drug / Alcohol Abuse YesNo
Fever Blisters / Herpes YesNo
Heart Attack / Stroke YesNo
Heart Murmur YesNo
Heart Surgery / Pacemaker YesNo
High / Low Blood Pressure YesNo
HIV+ / AIDS YesNo
Hospitalized for Any Reason YesNo
Kidney Problems YesNo
Mitral Valve Prolapse YesNo
Phychiatric Problems YesNo
Radiation Treatment YesNo
Rheumatic / Scarlet Fever YesNo
Sickle Cell Disease / Traits YesNo
Sinus Problems YesNo
Tuberculosis (TB) YesNo
Ulcers / Colitis YesNo
Venereal Disease YesNo
Any Metals/Plastics YesNo
Dental Anesthetics YesNo
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.
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.