Patient's Information
Patient's name:
Patient's Nickname
Patient's Preferred Pronoun
Patient's Birthdate
MM
/
DD
/
YYYY
Patient's Gender
Male
Female
Prefer Not to Answer
Other
Other
Patient's Address
Patient's phone number
Patient's Email Address
Patient's General Dentist
Patient's Hobbies
Which method(s) would you prefer to receive notifications of you future appointments? Check all that apply.
Email
Text Message
None
Billing Party's name:
Billing Party's Nick Name
Billing Party's Preferred Pronoun
Billing Party's Birthdate
MM
/
DD
/
YYYY
Billing Party's Gender
Male
Female
Prefer Not to Answer
Other
Other
Billing Party's Address
Billing Party's Home Number
Billing Party's Cell Number
Billing Party's Work Number
Marital Status
Single
Married
Widowed
Separated
Relationship to Patient
Please select
Self
Father
Mother
Aunt
Uncle
Grandmother
Grandfather
Guardian
Husband
Wife
Partner
Please select
Occupation
Employer
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Patient's Information
Policy Holder's Name (Last Name, First Name)
Policy Holder's Date of Birth
MM
/
DD
/
YYYY
Insurance Company Name
Insurance Company Phone Number
Policy Holder's Contract #
Group or Local Number
Secondary Policy Holder's Name (Last Name, First Name)
Secondary Policy Holder's Date of Birth
MM
/
DD
/
YYYY
Secondary Insurance Company Name
Secondary Insurance Company Phone Number
Secondary Policy Holder's Contract #
Secondary Group or Local Number
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Patient's Information
Physician's Name (Last Name, First Name)
Physician's Phone Number
Date of Last Visit
MM
/
DD
/
YYYY
Have the patient ever had any of the following medical concerns? (Check all that apply)
Abnormal Bleeding
Anemia
Artificial Bomes / Joints / Valves
Asthma / Arthritis
Blood Transfusion
Cancer / Chemothrapy
Congenital Heart Defects
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy / Seizures / Faiting
Fever Blisters / Herpes
Glaucoma
Heart Attack / Stroke
Heart Murmur
Heart Surgery / Pacemaker
Hemophilia
Hepatitis
High / Low Blood Pressure
HIV+ / AIDS
Hospitalized for Any Reason
Kidney Problems
Mitral Valve Prolapse
Psychiatric Problems
Radiation Treatment
Rheumatic / Scarlet Fever
Severe / Frequent Headaches
Shingles
Sickle Cell Diease / Traits
Veneral Disease
No Medical Concern
Ulcers / Colitis
Is the patient allergic to any of the following? (Check all that apply)
Aspirin
Any Metals / Plastics
Codeine
Dental Anesthetics
Erythromycin
Cancer / Chemothrapy
Latex
Penicillin
etracycline
Other (Please indicate in the entry below)
No Allergies
Other Allergies
Please list any medications now being taken by the patient
Please list any medications now being taken by the patient
Have the patient ever had any of the following dental concerns? (Check all that apply)
Has patient ever sucked thumb or fingers?
Does the patient breathe predominantly through the mouth?
Does the patient have any speech problems?
Does the patient clench or grind teeth (at night)?
Does the patient have pain or clicking upon closing the mouth?
Has the patient had any severe head or face injuries?
Have any teeth been chipped due to accidents?
Have you been informed of missing permanent teeth?
Have you been informed of any extra teeth?
Was it suggested that the space be maintained?
Were any teeth (baby or permanent) removed by extraction?
Was an appliance placed to maintain the space?
Have you ever had any previous orthodontic consultation or treatment?
Would patient mind wearing “braces”?
Any noticeable difficulty in chewing or swallowing food?
No Dental Concerns
Are you pregnant?
Yes
No
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Patient's Information
Emergency Contact's Name (Last Name, First Name)
Emergency Contact's relationship to patient
Emergency Contact's Phone Number
Verification
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