Name:

E-Mail Address:

I prefer to be called:

Gender: 1 : : Male Male  1 : : Female Female 

Birthdate:

SSN (to be filled at office):

Home Address Street:

City:

State:

Zip:

Marital Status:  Single   Married   Divorced   Widowed   Separated 

Home Phone Number:

Work Phone Number:

Employer:

Employer's Address:

How long there?

Occupation:

Where & when are the best times to reach you?

Whom may we thank for referring you?

Other family members seen by us:

General Dentist:

Last Visit Date:

Name of Spouse:

Employer:

Work Phone Number:

SSN (to be filled at office):

Birthdate:

Work Phone Number:

Home Phone Number:

Billing Address:

SSN (to be filled at office):

Employer:

Driver Licence:

Orthodontic Coverage:  Yes   No 

Dental Coverage:  Yes   No 

Insurance Co. Name:

Insurance Co. Address:

Insurance Co.Phone Number:

Group# (Plan, Local or Policy#):

Insured's Name (Relation):

Insured's Birthdate:

Insured's ID:

Insured's Employer:

Phone Number:

Dental Coverage:  Yes   No 

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone Number:

Group # ( Plan, Local or Policy # ):

Insured's Name:

Insured's Birthdate:

Insured's ID # :

Insured's Employer:

Date of last Visit:

Your current physical health is:  Good   Fair   Poor 

Are you currently under the care of a physician?  Yes   No 

Please explain:

Are you taking any prescription/over the counter drugs?  Yes   No 

Please list each one:

For women: are you using a prescribed method of birth control?  Yes   No 

Are you pregnant?  Yes   No 

Week#:

Are you nursing?  Yes   No 

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

Abnormal bleeding  Yes   No 

Anemia  Yes   No 

Artificial Bone/ Joints/valves  Yes   No 

Asthma /Arthritis  Yes   No 

Blood Transfusion  Yes   No 

Cancer/ chemotherapy  Yes   No 

Congenital Heart Defect  Yes   No 

Diabetes  Yes   No 

Difficulty Breathing  Yes   No 

Drug/ Alcohol Abuse  Yes   No 

Emphysema  Yes   No 

Epilepsy/ Seizures/ Fainting  Yes   No 

Fever Blisters/ Herpes  Yes   No 

Glaucoma  Yes   No 

Heart Attack/ Stroke  Yes   No 

Heart Murmur  Yes   NO 

Heart Surgery/ Pacemaker  Yes   No 

Hemophilia  Yes   No 

Hepatitis  Yes   No 

High/ Low Blood Pressure  Yes   No 

HIV+/ AIDS  Yes   No 

Hospitalized for any reason  Yes   No 

Kidney Problem  Yes   No 

Mitral Valve Prolapse  Yes   NO 

Psychiatric Problems  Yes   No 

Radiation Treatment  Yes   No 

Rheumatic/Scarlet Fever  Yes   NO 

Severe/ Frequent Headaches  Yes   No 

Shingles  Yes   No 

Sickle Cell Disease/ Traits  Yes   No 

Sinus Problem  Yes   No 

Tuberculosis(TB)  Yes   No 

Ulcers/ Colitis  Yes   No 

Venereal Disease  Yes   No 

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

Are you allergic to any of the following?

Aspirin  Yes   No 

Any Metals/ Plastics  Yes   No 

Codeine  Yes   NO 

Dental Anesthetics  Yes   No 

Erythromycin  Yes   No 

Latex  Yes   No 

Penicillin  Yes   No 

Tetracycline  Yes   NO 

Other  Yes   No 

Please list any other drugs/ materials that you are allergic to:

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

Have you ever had or been evaluated for orthodontic treatment?  Yes   No 

Have you ever had a serious/ difficult problem associated with any previous dental work?  Yes   No 

Do you now or have ever experienced pain/ discomfort in your jaw joint (TMJ/ TMD)?  Yes   No 

Your current dental health is:  Good   Fair   Poor 

Do you like your smile?  Yes   No 

Gums ever bleed?  Yes   NO 

Have you ever had an injury to your:  Mouth   Teeth   Chin 

Do you have any speech problems?  Yes   No 

Do you generally breathe through your mouth?  Yes   No 

If yes please select:  While Awake?   While Asleep? 

Do you have any missing or extra permanent teeth?  Yes   No 

Have you ever taken Fosamax, or any other bisphosphonate ?  Yes   No 

Have you ever taken Phen-Fen?  Yes   No 

Do you smoke or use tobacco in any form?  Yes   No 

Acknowledgment: 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 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.

Sign & Date the Acknowledgment:

Credit verification declaration: 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 discretion of the office, use the services of one or more credit reporting services.

Sign & Date Credit Acknowledgment:

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

Sign & Date Insurance Acknowledgment:

Office Use Only: I verbally reviewed the medical/ dental information above with the patient named herein. Initials:_________________ Date:___________________

Doctor's Comments: