* required field
Patient Information Patient Name *
Gender *
Social Security Number Birth Date * Driver's License Number Home Address * City * State * Zip *
Primary Phone Number * Primary Phone Number Phone Type Secondary Phone Number Secondary Phone Number Phone Type E-mail Address * Employer's Name Occupation
SPOUSE/EMERGENCY CONTACT INFORMATION Marital Status Spouse/Partner's Name Emergency Contact Name Phone Number Relation to you Address City State Zip
Person(s) OK to release appointment or medically related information to concerning you. Relation DENTAL INSURANCE INFORMATION Please provide your dental insurance details so we can verify your orthodontic benefits before your appointment. If this information is not provided, we may not be able to provide an accurate cost estimate at your visit.
Primary Insurance Company Insurance Company Name Subscriber (Policy Holder) Name Subscriber Birth Date Subscriber SSN Relation to Patient Member ID Number Group Number Employer
Insurance Company Name Subscriber (Policy Holder) Name Subscriber Birth Date Subscriber SSN Relation to Patient Member ID Number Group Number Employer DENTAL HISTORY 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?*
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? * 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 allergies: Are you currently taking any prescription or over-the-counter medications? * Please list, with dosage: Have you ever taken intravenous bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate), or Didronel (etidronate)? * Have you ever taken oral medication for bone disorders or cancers such as bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate), or Didronel (etidronate)? * Have you had any serious illnesses or operations? If yes, describe: * 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 or have ever had any of the following: * 
