Online Patient Form PATIENT DETAILS Patient’s First Name Patient’s Last Name Nickname Patient’s Address City State State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Gender Gender Female Male Home Phone Date of birth Age Race Race American Indian Asian African American Hispanic or Latino Pacific Islander White Other Cell Phone School/Employer Grade/position Work phone How did you hear about our office Email Family members treated in our office Reason for Consultation Previous Dentist Date of last cleaning Yes No Has the patient been examined by an orthodontist before? If the Guardian & the Patient are the same person, please click here to copy patient information to the next page. GUARDIAN #1 / INSURANCE INFORMATION Self Spouse Father Mother Stepparent Other (specify) Guardian’s First Name Guardian’s Last Name Home Phone Address City State State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Employer Work Phone Date of birth Social Security Number Cell Phone Guardian’s E-Mail INSURANCE (IF APPLICABLE): Company Name Phone Subscriber/Member ID GUARDIAN #2 / INSURANCE INFORMATION Yes No Is there a second guardian and / or additional insurance to add? Self Spouse Father Mother Stepparent Other (specify) Guardian’s First Name Guardian’s Last Name Home Phone Address City State State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Employer Work Phone Date of birth Social Security Number Cell Phone Guardian’s E-Mail ORTHODONTIC INSURANCE (IF APPLICABLE): Company Name Phone Subscriber/Member ID SLEEP / AIRWAY ISSUES Yes No Does 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? DENTAL/MEDICAL HISTORY Please check if the patient has a history of the following medical conditions: Yes No 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 Any dental restorations needing to be completed? Yes No Have there ever been any injuries to the face, mouth or chin? Yes No Have you ever lost or chipped any teeth? Yes No Do you have any pain or soreness around your face, neck or back? Yes No Is any part of your mouth sensitive to temperature or pressure? Yes No Is the patient currently pregnant? Yes No Have adenoids been removed? Yes No Have tonsils been removed? Yes No Currently taking any medications? Yes No Are antibiotics necessary prior to treatment? Yes No Allergies? Yes No Any diseases or problems not mentioned above? Please check if the patient has, or ever had, any of the following habits? Yes No 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 SIGNED CONSENT I 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. Typed Name/Signature Relationship to Patient Date If someone other than the parent(s) or guardian(s) listed above will be bringing the patient to appointments, please list here: By submitting this form you agree to the above mentioned consent statement Submit Your request has been sent — we will be in contact with you shortly. There was an error! Please phone our office. Previous Next
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