Online Patient Form

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?

Yes No

Please check if the patient has a history of the following medical conditions: *

Do your gums bleed when you brush?

Yes No

Is the patient seeing any other dental specialists?

Yes No

(eg. Periodontist)

Any dental restorations needing to be completed?

Yes No

What?

Have there ever been any injuries to the face, mouth or chin?

Yes No

Explain

Have you ever lost or chipped any teeth?

Yes No

Which tooth/teeth

Do you have any pain or soreness around your face, neck or back?

Yes No

Explain

Is any part of your mouth sensitive to temperature or pressure?

Yes No

Explain

Is the patient currently pregnant?

Yes No

Due Date

Date

Have adenoids been removed?

Yes No

When

Have tonsils been removed?

Yes No

When

Currently taking any medications?

Yes No

List here

Are antibiotics necessary prior to treatment?

Yes No

List here

Allergies?

Yes No

(ie:., Drug Latex, etc)

Any diseases or problems not mentioned above?

Yes No

List here

Please check if the patient has, or ever had, any of the following habits?

Cheek, tongue or lip biting Clenching Teeth Fingernail Biting Type option 4

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

Clear

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.

Online Patient Form

PATIENT DETAILS

GUARDIAN #1 / INSURANCE INFORMATION

INSURANCE (IF APPLICABLE):

GUARDIAN #2 / INSURANCE INFORMATION

ORTHODONTIC INSURANCE (IF APPLICABLE):

SLEEP / AIRWAY ISSUES

DENTAL/MEDICAL HISTORY

SIGNED CONSENT