Patient InformationPatient Name* First Last Gender Male FemaleBirth Date MM slash DD slash YYYY Home Address Street Address Address Line 2 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 Email Address* Driver's License NumberPrimary Phone*Phone TypeHomeCellSecondary PhonePhone TypeHomeCellEmployerOccupationSpouse/Emergency ContactMartial StatusSingleMarriedDivorcedWidowedSignificant OtherSpouse/Partner's NameEmergency Contact Name First Last PhoneRelation to YouAddress Street Address Address Line 2 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 Person(s) OK to release appointment or medically related information to concerning you.Insurance InformationPrimary InsurancePrimary Insurance CompanyPhone NumberGroup NumberPolicy NumberMember ID NumberPolicy Holder's Name First Last RelationBirth Date MM slash DD slash YYYY EmployerWork Phone NumberCo-pay (if known)Deductible (if known)Secondary InsuranceSecondary Insurance CompanyPhone NumberGroup NumberPolicy NumberMember ID NumberPolicy Holder's Name First Last RelationBirth Date MM slash DD slash YYYY EmployerWork Phone NumberCo-pay (if known)Deductible (if known)Dental HistoryGeneral DentistLast VisitHow did you hear about our practice?AdInternetFamily or FriendPhysicianOtherName of person referringWhat are the main concerns you would like orthodontics to accomplish?Have you visited an orthodontist before?YesNoWhen and for what reason?Have you had your tonsils or adenoids been removed?YesNoHave you ever experienced jaw joint pain/discomfort (TMJ/TMD)?YesNoDo you have any missing or extra permanent teeth?YesNoHave you ever had an injury to (select all that apply): Teeth Mouth ChinDo you have speech problems?YesNoWhat kind of speech problems?Do your gums bleed?YesNoDo you smoke?YesNoDo you like your smile?YesNoDo you currently or ever had any of the following habits? Clenching/Grinding Teeth Lip Sucking/Biting Mouth Breathing Nail Biting Thumb/ Finger Sucking Chewing/Eating ProblemsMedical HistoryAre you currently being treated by a physician?YesNoReasonPhysicianPhone NumberDo you have any allergies/sensitivities to medications or latex?YesNoList allergiesAre you currently taking any prescription or over-the-counter medications?YesNoPlease list, with dosage:Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?YesNoHave you had any serious illnesses or operations?YesNoDescribe:Have you ever had a blood transfusion?YesNoGive approximate dates:Are you pregnant?YesNoAre you nursing?YesNoAre you taking birth control?YesNoCheck if your child has or have ever had any of the following: Anemia Arthritis, Rheumatism Artificial Heart Valves Artificial Joints Asthma Back Problems Blood Disease Cancer Chemical Dependency Chemotherapy Circulatory Problems Cortisone Treatments Cough, Persistent Coughing Blood Diabetes Epilepsy Fainting Glaucoma Headaches Heart Murmur Heart Problems Hemophilia Hepatitis High Blood Pressure HIV/AIDS Jaw Pain Kidney Disease Liver Disease Mitral Valve Prolapse Pacemaker Radiation Treatment Respiratory Disease Rheumatic Fever Scarlet Fever Shortness of Breath Skin Rash Stroke Swelling of Feet or Ankles Thyroid Problems Tobacco Habit Tonsillitis Tuberculosis Ulcer Venereal DiseaseI understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.Patient Signature and/or Responsible Party First Last Date MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.Δ