Malia Pietsch Kamisugi DDS MSD
“Keeping Hawaii Smiling”



 

Patient’s Name


Age


Sex


Birth Date 


Home Address


City


Zip


Home #


School


Grade


Cell #


Email Address


Father’s Name


Cell #


Work #


Email address


Occupation


Employed by


Mother’s Name


Cell #


Work #


Email address


Occupation


Employed by


Parent’s Marital Status:                                              Single   Married   Separated   Divorced  Widowed 

Patient lives with:                                                       Parents   Father   Mother    Guardian

Guardians Name


Name and Ages of Other Children in the Family


Has anyone in your immediate family had orthodontic treatment with us?


If so, who?


Is there anyone else that would like to be seen by us today?


Referred by


Relationship to you


Dentist’s Name


Location  


Last dental cleaning:


Date of next cleaning: 


WHO WILL BE FINANCIALLY RESPONSIBLE FOR THIS ACCOUNT?  

Name


Relationship


Telephone #


Home address


Business #  


Email address 

INSURANCE INFORMATION 

Do you have Dental Insurance?                                                                 Yes    No   

Carrier  


Subscriber Name  


Subscriber ID/SS#


Subscriber Date of Birth  

MEDICAL HISTORY

Is the patient in good health?                                                                    Yes    No

Has the patient ever had any serious illness?                                            
Yes    No

Has the patient ever been hospitalized or had any major operations?      
Yes    No
If so, please explain: 


Is the patient under the care of a physician?                                             
Yes   No

Physician’s Name


Phone#


Condition being treated  


Has the patient been treated for any of the following?
 AIDS   Drug Reaction   Hepatitis   Pneumonia
 Allergies   Endocrine   Herpes   Rheumatic Fever
  Anemia   Epilepsy   HIV   Tuberculosis
  Asthma   Fainting/Dizziness   Kidney Trouble   Venereal Disease
  Bone Disorders   Heart Problems   Leukemia   Diabetes
  Hemophilia    Liver Trouble   High Blood Pressure  


Are there any medical conditions that would have any effect on orthodontic treatment or that we should know about?
Yes   No

If yes, describe:


Does the patient have glaucoma?                                   
Yes    No

Does the patient have a tendency for:                             
colds   sore throats   canker sores    ear infections

Have tonsils and adenoids been removed?                     
Yes   No

At what age?


List any drugs or medications now being taken:


Please give reasons:


The above information is complete and true to my knowledge.


Patient Name


Signature


Date