Patient Information * Patient Name: (Required)
Gender Social Security Number: Birth Date: Driver License: Home Address: City: State: Zip: Primary Phone: Primary Phone Ok to leave message? Secondary Phone: Secondary Phone Ok to leave message? * E-mail: (Required) Employer's Name: Occupation: Spouse / Partner Information Marital Status Spouse/Partner's Name: Emergency Contact Name: Phone Number: Relation: Address: City: State: Zip:
Person(s) OK to release appointment or medically related information to concerning you: Relation(s): Insurance Information Primary Insurance Company: Phone Number: Group Number: Policy Number: Member ID Number: Policy Holder's Name: Relation: Policy Holder's SSN: Policy Holder's Date of Birth: Employer: Work Phone Number: Co-pay (if known): Deductible (if known):
Secondary Insurance Company: Phone Number: Group Number: Policy Number: Member ID Number: Policy Holder's Name: Relation: Policy Holder's SSN: Policy Holder's Date of Birth: Employer: Work Phone Number: Co-pay (if known): Deductible (if known):
Dental History General Dentist: General Dentist Last Visit: How did you hear about our Practice? Name of person referring (if applicable) : What are the main concerns you would like orthodontics to accomplish? Concerns: Have you visited an orthodontist before? When: Reason: Have your tonsils or adenoids been removed? Have you ever experienced jaw joint pain/ discomfort (TMJ/TMD)? Do you have any missing or extra permanent teeth? Have you ever had an injury to (select all that apply): Do you have speech problems? If so, explain: Do your gums bleed? Do you smoke? Do you like your smile? Do you currently or have you ever had any of the following habits (check all that apply) Medical History Are you currently being treated by a physician? Reason: Physician: Last Visit: Phone: Do you have any allergies/sensitivities to medications or latex? If yes, please list: Are you currently taking any prescription or over-the-counter medications? Please list, with dosage: Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)? Have you had any serious illnesses or operations? If yes, describe: Have you had any serious illnesses or operations? If yes, describe Have you ever had a blood transfusion? If yes, give approximate dates: (Women) Are you pregnant? Nursing? Taking birth control pills? Check if you have ever had any of the following: 