Patient Forms

Please take a minute to fill out and submit the online patient information form before your first appointment:

Confidential Biographical Information

First Name(Required)

First

Middle Initial

Last Name(Required)

Last

Name

Nickname

Birthdate(Required)

Gender(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Main Phone(Required)

2nd/ Cell Phone

Social Security Number

If patient is a minor, give parent's or guardian's name:

If patient is a minor, who does the patient live with?

Please list the names of any friends or family currently in the practice:

List any sports, hobbies, or musical instruments played:

Whom may we thank for referring you to our practice?

Confidential Financial Party Information

Is the patient also the person who will be financially responsible for treatment?

Yes

First Name(Required)

First

Middle Initial

Last Name(Required)

Last

Marital Status:

Relationship to Patient:

Birthdate(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How long at this address?

Previous Address (less than 3 years):

Main Phone(Required)

2nd/ Cell Phone

Work Phone

Social Security #:

Employer:

Occupation

Length of Employment

Spouse or Other Parent's First Name

First

Middle Initial

Last Name

Last

Relationship to Patient:

Social Security Number

Birthdate(Required)

Employer:

Occupation

Length of Employment

Work Phone

Dental Insurance Information

Policy Holder's Name:

First Last

Relationship to Patient:

Policy Holder's Employer:

Insurance Company:

Subscriber ID #

Group No.:

Insurance Co. Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insurance Co. Phone No.:

Do you have dual dental coverage?

Yes

Policy Holder's Name:

First Last

Relationship to Patient:

Policy Holder's Employer:

Insurance Company:

Subscriber ID #

Group No.:

Insurance Co. Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insurance Co. Phone No.:

Emergency Information

Name of nearest relative not living with you:

Complete Address:

Phone

Relationship to Patient:

Dental History

Dentist Name:

Check-up Frequency:

Last Dental Visit:

Has the patient had an orthodontic consult or treatment?

Yes

If so, when?

Does the patient need to premedicate prior to dental visit?(Required)

Yes

What is the patient's main orthodontic concern?

Please select if the patient has had any of the conditions listed below either now or in the past.(Required)

If any of the above dental questions were answered 'Yes', and selected, please explain:

Please select if the patient has had any of the conditions listed below either now or in the past.

Brush teeth daily?

Floss teeth daily?

Fluoride treatments?

Have wisdom teeth been removed?

If any of the above dental questions were answered 'No', and NOT selected, please explain:

Please select if the patient has had any of the conditions listed below either now or in the past.

Have you had a TMJ screening?

Do you have a history of jaw joint problems?

Have you been treated for TMJ?

Do you notice clicking or popping in your jaw joint?

Do you clench your teeth?

Has your jaw ever locked?

Do you have difficulty chewing or opening your mouth?

Does your bite feel uncomfortable or unusual?

Do you experience soreness in the muscles of your face or around your ears?

If any of the above dental questions were answered 'Yes', and selected, please explain:

Medical History

Physician Name

First Last

Date of Last Physical:

Patient Health

Physician Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Has there been any change in the patient's general health within the last year?(Required)

Yes

Is the patient now under the care of a physician (other than routine)?(Required)

Yes

If you answered "YES" to the above, what is being treated?

Has the patient had a serious illness/hospitalization in the past 5 years?(Required)

Yes

If you answered "YES" to the above, please explain:

List any medications currently being taken by the patient (include non-prescription):

Please select if the patient has allergies or drug reaction to:(Required)

List any drug allergies or sensitivities (not listed above) that the patient may have:

Please select if the patient has had any of the conditions listed below either now or in the past:(Required)

If any of the above medical questions were answered 'Yes' , please explain:

Patient Motivation for Orthodontic Treatment

Patients often request changes in their bites or faces and relief from pain or discomfort. Please help us to understand your concerns by checking the following information; please be specific (check the words - upper, lower, more, etc.)

Teeth

If your teeth could be changed, how would you like them to change?

If you selected 'other' please explain:

Face

If your facial appearance could be changed, what would you change?

Symptoms

If you want to reduce pain or discomfort, please be specific about its location; check the right or left side or both if they apply.

If you selected 'other' please explain:

Patients Under 18

If patient is under the age of 18, please answer the following questions:

Height

Weight

School

Grade

Has patient begun puberty:

Yes

If patient is a girl, has menstruation begun:

Yes

If patient is a boy, has their voice changed or have facial hair:

Yes

Has the patient grown in the past year or has their shoe size changed recently:

Yes

Has either biological parent ever had orthodontic treatment:

Consent

Check the boxes below to agree to the following:(Required)

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.

I understand that where appropriate, credit bureau reports may be obtained.