Patient Information Form

Patient Information Form
Patient Name

First NameLast Name
Common Name
Gender
Age
Birth Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name (If under 18)
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Carrier
Email Address
example@example.com
Responsible Party's Information
Name

First NameLast Name
Marital Status
Birth Date

MonthDayYear
Date
Relation to patient
Mailing Address (If different from patient address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Do you own or rent?
Previous Address (if less than 3 yrs)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Occupation
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Years Employed
Spouse
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Relation to Patient
Employer
Occupation
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Years Employed
Insurance Information
Do you have insurance coverage?
Insured's Name

First NameLast Name
Insured's SSN
Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Co.
Group No.
Subscriber ID #
Insurance Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Co. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have Dual Coverage?
Insured's Name

First NameLast Name
Insured's SSN
Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Co.
Group No.
Subscriber ID #
Insurance Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Co. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Information
Name of nearest relative not living with you
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I certify that the above information is accurate and I agree to inform this office of any changes to the above information in the future. I understand that, where appropriate, credit bureau reports may be obtained.
Whom may we thank for referring you to our office?
Medical History
Physician
Dentist
Does the patient:
Have any health problems (current or past)
If yes, please explain.
Take any medications (current or past)
If yes, please explain.
Currently see a physician
If yes, please explain.
Have allergies to anything
If yes, please explain.
Have a history of illness or hospitalizations
If yes, please explain.
Use drugs, alcohol or tobacco
If yes, please explain.
Have trouble breathing through the nose
If yes, please explain.
Have a tendency for ear infections
If yes, please explain.
Have a history of bumps to the chin or trauma to the face, teeth or jaws
If yes, please explain.
Have any pain, clicking or noises in the jaw joint or head/neck regions
If yes, please explain.
Experience frequent headaches
If yes, please explain.
Play any wind/reed instruments or the violin
If yes, please explain.
Have negative reactions or experiences to any type of dental work
If yes, please explain.
Need to take medication before dental work because of a heart/valve condition
If yes, please explain.
Have airway concerns or been diagnosed with Sleep Apnea
If yes, please explain.
Have a history of thumb sucking, if yes, until what age?
If yes, please explain.
Has the patient ever had any of the following:
For the Female Patient...is the patient now:
Pregnant?
Taking Birth Control?
Have you ever taken Bisphosphonates for bone density?
Are you currently taking Bisphosphonates?
Please explain fully any “Yes” answers above or any family history of any of the above conditions.
Please explain your orthodontic concerns and what you would like orthodontics to accomplish for you.
Signature

I certify that the information above is true and accurate and that if there are any changes in this medical history, I will notify this office. I agree to allow Dr. Chandler and/or Dr. Anderson to discuss or share this information with whomever they deem necessary
Patient/Legal Guardian Signature
Date

MonthDayYear
Date
Should be Empty:

Patient Information Form

Responsible Party's Information

Spouse

Insurance Information

Emergency Information

Medical History

Does the patient:

For the Female Patient...is the patient now:

Signature