Patient DetailsPatient's First Name(Required) Patient's Last Name(Required) Nickname Patient's Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneWork PhoneGenderGenderFemaleMaleDate of birth MM slash DD slash YYYY Age(Required) RaceRaceAmerican IndianAsianAfrican AmericanHispanic or LatinoPacific IslanderWhiteOtherSchool/Employer Grade/position Email How did you hear about our office?(Required) Family members treated in our office Reason for Consultation(Required) Previous Dentist(Required) Date of last cleaning MM slash DD slash YYYY Has the patient been examined by an orthodontist before? Yes No Guardian #1 / Insurance InformationGuardian #1 / Insurance Information Self Spouse Father Mother Stepparent Other Guardian's First Name Guardian's Last Name Home PhoneAddress(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer(Required) Work PhoneDate of birth MM slash DD slash YYYY Social Security Number Cell PhoneGuardian's Email(Required) Insurance (if applicable):Company Name PhoneSubscriber/Member ID Guardian #2 / Insurance InformationIs there a second guardian and / or additional insurance to add? Yes No Guardian #1 / Insurance Information Self Spouse Father Mother Stepparent Other Guardian's First Name Guardian's Last Name Home PhoneAddress(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer(Required) Work PhoneDate of birth MM slash DD slash YYYY Social Security Number Cell PhoneGuardian's Email(Required) Insurance (if applicable):Company Name PhoneSubscriber/Member ID Sleep / Airway IssuesDoes the patient tend to be a mouthbreather? Yes No Does the patient snore at night? Yes No Does the patient seem rested in the morning? Yes No Is the patient often sleepy during the day? Yes No Has the patient seen an Ear, Nose, & Throat Specialist? Yes No Is the patient using a sleep apnea device? Yes No Dental/Medical HistoryPlease check if the patient has a history of the following medical conditions:Acid Reflux Yes No ADHD/ADD Yes No AIDS/HIV Yes No Anemia Yes No Arthritis Yes No Asthma Yes No Autism Yes No Bone Disorders Yes No Cancer Yes No Cerebral Palsy Yes No Chest Pain Yes No Chronic Neck Pain Yes No Clicking of Jaw Yes No Jaw Pain Yes No Cold Sores/Herpes Yes No Diabetes Yes No Down Syndrome Yes No Endocrine Problems Yes No Emotional Disorders Yes No Epilepsy Yes No Headaches Yes No Heart Condition Yes No Hepatitis Yes No Ear Pain Yes No Immune Problems Yes No Kidney Problems Yes No Low Blood Pressure Yes No Muscular Disorders Yes No Nervous Disorders Yes No Organ Transplant Yes No Osteoporosis Yes No Painful Chewing Yes No Periodontal Problems Yes No Prolonged Bleeding Yes No Rheumatic Fever Yes No Scoliosis Yes No Seizures Yes No Sinus Problems Yes No TMJ Problems Yes No Tuberculosis Yes No Do your gums bleed when you brush? Yes No Is the patient seeing any other dental specialists? Yes No (e.g., periodontist) Any dental restorations needing to be completed? Yes No What? Have there ever been any injuries to the face, mouth, or chin? Yes No Explain: Have you ever lost or chipped any teeth? Yes No Which tooth/teeth? Do you have any pain or soreness around your face, neck, or back? Yes No Explain: Is any part of your mouth sensitive to temperature or pressure? Yes No Explain: Is the patient currently pregnant? Yes No Due date? Have adenoids been removed? Yes No If yes, when? Have tonsils been removed? Yes No If yes, when? Currently taking any medications? Yes No List here. Are antibiotics necessary prior to treatment? Yes No List here. Allergies? Yes No (i.e., Drug, Latex, etc.) Any diseases or problems not mentioned above? Yes No List here. Please check if the patient has, or ever had, any of the following habits?Cheek, tongue, or lip biting Yes No Clenching Teeth Yes No Fingernail Biting Yes No Grinding Teeth Yes No Tongue Sucking Yes No Thumb Sucking Yes No Tongue Thrusting Yes No Signed ConsentI understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient’s medical status. I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate orthodontic treatment on the above-named patient. I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.Type Name/Signature(Required) Relationship to Patient(Required) Date(Required) MM slash DD slash YYYY If someone other than the parent(s) or guardian(s) listed above will be bringing the patient to appointments, please list here:Please list here: By submitting this form you agree to the above mentioned consent statement. Δ
