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Patient Information

Spouse/Emergency Contact Information

Insurance Information

Dental History

What are the main concerns you would like orthodontics to accomplish?

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 currently or have you ever had any of the following habits?

Medical History

Are you currently being treated by a physician?

Do you have any allergies/sensitivities to medications or latex?

Are you currently taking any prescription or over-the-counter medications?

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?

Have you had any serious illnesses or operations? If yes, describe:

(Women)

Check if you have or have ever had any of the following: Required

Authorization

I 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 obtined.

Patient Information

Emergency Contact Information

Insurance Information

Dental History

What are the main concerns you would like orthodontics to accomplish?

Has your child's tonsils or adenoids been removed?

Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?

Does your child you have any missing or extra permanent teeth?

Has your child ever had an injury to (select all that apply):

Does your child currently or has your child ever had any of the following habits?

Medical History

Is your child currently being treated by a physician?

Does your child have any allergies/sensitivities to medications or latex?

Has your child had any serious illnesses or operations? If yes, describe:

Have your child ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?

Has your child had any serious illnesses or operations? If yes, describe:

Check if your child has or have ever had any of the following: Required

Authorization

I 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.

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