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Patient information

How'd you find us?*

Select*FacebookGoogle SearchInstagramNextdoorSchool BannerWord of mouthYelpOther
 

Rate our new website*:

Select*5 - Epic4 - Awesome3 - Good2 - Ok1 - Bad
 

First name*:

 

Last name*:

 

Nickname:

 

Date of birth*:

 

Age:

 

Gender:

SelectFemaleMale
 

Marital status:

SelectSingleMarriedDivorcedWidowed
 

Address*:

 

City*:

 

State*:

 

Zip code*:

 

Mobile number*:

 

Mobile carrier*:

SelectAT&TSprintT-MobileUS CellularVerizonVirgin MobileOther
 

Email*:

 

Name(s) of family members seen by Dr. Smith:

 

Name of your employer:

 

Occupation or title:

Work number & EXT:

 

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Emergency contact

Full name:

 

Relationship:

 

Phone:

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Responsible party

First name*:

 

Middle name:

 

Last name*:

 

Date of birth*:

 

Relationship to the patient*:

 

Address*:

 

City*:

 

State*:

 

Zip code*:

 

Home number*:

 

Mobile number*:

 

Work number & EXT:

 

Email*:

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Insurance information

Do you have orthodontic insurance?*

Select*YesNo
​​​​​​

Primary insurance

Feel free to upload your insurance card:

Front side:

Back side:

Name of dental insurance*:

Insurance phone #*:

Policy owner's name*:

Policy owner's birth date*:

Social security / ID #*:

Policy owner's employer*:

Relationship to patient*:

 

Secondary insurance

Feel free to upload your insurance card:

Front side:

Back side:

Name of dental insurance:

Insurance phone #:

Policy owner's name:

Policy owner's birth date:

Social security / ID #:

Policy owner's employer:

Relationship to patient:

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Medical history

Have you been diagnosed or treated for a medical condition?*

Select*YesNo
​​​​

ADHD*
 Yes   No

Aids/HIV positive*
 Yes   No

Autism*
 Yes   No

Anemia*
 Yes   No

Anxiety*
 Yes   No

Cancer*
 Yes   No
 

Diabetes*
 Yes   No

Difficulty Breathing*
 Yes   No

Drug/Alcohol Abuse*
 Yes   No

Emotional Problems*
 Yes   No

Epilepsy*
 Yes   No

Heart Condition*
 Yes   No
 

Heart Murmur*
 Yes   No

Hepatitis*
 Yes   No

Lung Disorders*
 Yes   No

Psychiatric Problems*
 Yes   No

Radiation Treatment*
 Yes   No

Sinus Problems*
 Yes   No
 

Speech/Hearing Problems*
 Yes   No

Tuberculosis*
 Yes   No

Vision Problems*
 Yes   No
 

Are you in good health?*

Select*YesNo
 

If "No", please explain. If "Yes", type "In Good Health"*:

 

Your physician’s name*:

 

Date of your last visit?*:

 

Are you taking any medications (include over-the-counter)?*

Select*YesNo
 

List any daily medications you are presently taking. Else, type "None"*:

 

Have you ever been diagnosed with Osteoporosis, bone density concerns or taken Bisphosphonates?*

Select*YesNo
 

Have your adenoid and/or tonsils been removed?*

Select*YesNo
 

If "Yes", when? Else, type "None"*:

 

Do you suffer from allergies?*

Select*YesNo
 

Anesthetics*
 Yes   No

Aspirin*
 Yes   No

Amoxicillin*
 Yes   No
 

Codeine*
 Yes   No

Cyclosporins*
 Yes   No

Erythromycin*
 Yes   No
 

Latex*
 Yes   No

Nickel*
 Yes   No

Penicillin*
 Yes   No
 

Sulfa Drugs*
 Yes   No

Tetracycline*
 Yes   No

Other*
 Yes   No
 

If you selected "Other", please list any other medicines or materials you may be allergic to. Else, type "None"*:

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Dental history

Date of your last dental visit*:

 

Current general dentist name*:

 

General dentist phone*:

 

Have had complications following dental treatment?*
 Yes   No

Ever injured any teeth?*
 Yes   No

Ever injured jaw or face?*
 Yes   No

Currently have cavities/toothaches that need treatment?*
 Yes   No

Needs to be pre-medication before dental treatment?*
 Yes   No

Please explain the items you have answered "Yes". Else, type "None"*:

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Acknowledgement

I have examined the above information and it is true and correct.

Signer first name*:

 

Signer last name*:

 

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