PATIENT INTAKE INFORMATION
Today's Date
/
Month
/
Day
Year
Date
Patient's Name
*
First Name
Last Name
Prefers to be Called (Optional)
Gender
Male
Female
Date of Birth
*
/
Month
/
Day
Year
Date
Age
Patient's Primary Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is the primary reason(s) why you are interested in orthodontic treatment?
Name of General (Family) Dentist
Approximate Date of Last Dental Visit
-
Month
-
Day
Year
Date
Who may we thank for referring you to our office?
Family Dentist
Friend
Internet Search
Social Media
Other
Child Patient Information
School
Grade
What hobbies and activities do you love to do?
Patient lives with (please check all that apply)
Mother
Father
Stepmother
Stepfather
Grandparent
Other Guardian
Other
Who will be the primary contact to arrange appointments?
Who will be bringing the patient to their orthodontic appointments?
Please name any other persons with whom we can share patient information (Step-parent, grandparents, etc)
Does the patient have their own phone where you would want appointment reminders to be sent?
Yes
No
Patient's Phone Number
-
Area Code
Phone Number
End Child Patient Information
Adult Patient Information
Occupation
Employer
Patient Contact Information
Cell Phone
-
Area Code
Phone Number
Send Text Reminders
Work Number (If applicable)
-
Area Code
Phone Number
Home Number (If applicable)
-
Area Code
Phone Number
Primary Email
example@example.com
Email Appointment Reminders
Alternative Email (If applicable)
example@example.com
End Adult Patient Information
Mother's Information
Mother's Name
First Name
Last Name
Mother's Date of Birth
-
Month
-
Day
Year
Date
Is Mother's Address the same as the patient's address?
Yes
No
Mother's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Occupation
Mother's Place of Employment
MOTHER'S CONTACT INFORMATION
Mother's Cell Phone
-
Area Code
Phone Number
Send Text Reminders
Mother's Work Number (If applicable)
-
Area Code
Phone Number
Mother's Home Number (If applicable)
-
Area Code
Phone Number
Mother's Primary Email
example@example.com
Email Appointment Reminders
Mother's Alternative Email (If applicable)
example@example.com
End Mother' Information
Father's Information
Father's Name
First Name
Last Name
Father's Date of Birth
-
Month
-
Day
Year
Date
Is Father's Address the same as the patient's address?
Yes
No
Father's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Occupation
Father's Place of Employment
FATHER'S CONTACT INFORMATION
Father'sCell Phone
-
Area Code
Phone Number
Send Text Reminders
Father's Work Number (If applicable)
-
Area Code
Phone Number
Father's Home Number (If applicable)
-
Area Code
Phone Number
Father's Primary Email
example@example.com
Email Appointment Reminders
Father's Alternative Email (If applicable)
example@example.com
End Father's Information
Guardian's Information
Guardian's Name
First Name
Last Name
Guardian's Date of Birth
-
Month
-
Day
Year
Date
Is Guardian's Address the same as the patient's address?
Yes
No
Guardian's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Guardian's Occupation
Guardian's Place of Employment
GUARDIAN'S CONTACT INFORMATION
Guardian's Cell Phone
-
Area Code
Phone Number
Send Text Reminders
Guardian's Work Number (If applicable)
-
Area Code
Phone Number
Guardian's Home Number (If applicable)
-
Area Code
Phone Number
Guardian's Primary Email
example@example.com
Email Appointment Reminders
Guardian's Alternative Email (If applicable)
example@example.com
End Guardian's Information
Financial Information
Who will be responsible for this account?
*
Does the patient have dental insurance?
*
One Insurance Policy
Two Insurance Policies
None
End Financial Information
Primary Insurance Information
Primary Insurance Policyholder
Father
Mother
Patient
Other
Primary Policyholder's Full Name
First Name
Last Name
Primary Policyholder's Date of Birth
-
Month
-
Day
Year
Date
Primary Policyholder/s Employer
Primary Insurance Company Name
Does this policy provide orthodontic benefits?
Yes
No
I Don't Know
Primary Policy Member ID
Primary Policy Group ID
Policy Holder SS#
Primary Insurance Phone Number
-
Area Code
Phone Number
Second Insurance Section
Second Insurance Policyholder
Father
Mother
Patient
Other
Second Policyholder's Full Name
First Name
Last Name
Second Policyholder's Date of Birth
-
Month
-
Day
Year
Date
Second Policyholder's Employer
Second Insurance Company Name
Does this policy provide orthodontic benefits?
Yes
No
I Don't Know
Second Policy Member ID
Policy Owner SS#
Second Policy Group ID
Second Insurance Phone Number
-
Area Code
Phone Number
End Insurance Information
Dental and Medical History
Primary Care Physician
City
End Dental and Medical History
Have you had allergies or reactions to any of the following? (Check all that apply)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin
Metals (Jewelry, Clothing Snaps)
Acrylics
Other
Dental History
How often do you brush your teeth?
Please check each row
*
No
Yes
Explanation
Errupting teeth very early or very late
Primary (baby) teeth removed that were not loose
Teeth causing irritation to lip, cheek or gums
Permanent or extra (supernumerary) teeth removed
Supernumerary (extra) or congenitally missing teeth
Clicking or locking in jaw joints
Chipped or injured primary or permanent teeth
Soreness in jaw muscles or face muscles
Mouth breathing habit or snoring at night
Difficulty breathing through nose
Jaw fractures, cysts, or infections
History of speech problems or speech therapy
Frequent oral habits such as sucking finger, chewing pen, etc.
Any teeth treated with root canals or pulpotimies
Frequent canker sores or cold sores
Treatment for "TMJ" or "TMD" problems
Any serious trouble associated with previous dental treatment
Gum disease or pyorrhea
Previous orthodontic treatment and or orthodontic consultation
Other (Please explain)
Medical History
Please check each row
No
Yes
Explanation
Frequent headaches or migraines
Birth defects or hereditary problems
Bone fractures or major injuries
Excessive bleeding or bruising or anemia
Injuries to facc e, head, or neck
Angina, arteriosclerosis, stroke or heart attack
Asthma
Sinus problems
Hay fever
Cancer, tumor, radiation treatment or chemotherapy
Heart defects, heart murmur, or rheumatic heart disease
Endocrine or thyroid problems
Skin disorder (other than common acne)
Vision problems (other than common near/far-signtedness)
Hearing problems
Frequent ear infections, colds, or throat infections
Chest pain, shortness of breath, tire easily, or swollen ankles
Gonorrhea, syphilis, herpes, or other sexually transmitted diseases
Seizures, fainting spells, neurologic problems
Hepatitis, jaundice, or other liver problems
Mental health disturbance e or depression
Eat an unbalanced diet
History or eating disorder (anorexia, bulimia)
Chest pain, shortness of breath, tire easily, or swollen ankles
Has the patient taken, or is currently taking any of the following medications for bone disorders or cancer?
Fosamax (alendronate)
Actone(ridendronate)
Boniva (ibandronate)
Skelid (tiludronate)
Didronel (etidronate)
Zometa (zolendromic acid)
Aredia (pamidronate)
Date of Signatures
-
Month
-
Day
Year
Date
Privacy Consent: I authorize release of any information regarding my child's orthodontic treatment to my dental and/or medical insurance company. This may include names, dates, phone/fax numbers, email addresses, mailing address, social security numbers, and demographic data. (you have the right to request restrictions on the use of your protected health information, however, we are not required to, and may not honor your request. You may revoke this consent at any time in writing for any further actions.
I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in the patient's medical or dental health.
*
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