duanorthodontics.com-Health History

Patient Information
Date

Month Day Year
Patient's Name

First Name Middle Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone

Area Code Phone Number
Social Security#
Birthdate

Month Day Year
Age
If patient is a minor, give parent's or guardian's name

First Name Last Name
Whom may we thank for referring you to our office?
Responsible Party Information
Name

First Name Middle Name Last Name
Marital status
Residence

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How long at this address
Home phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Previous Address (if less then 3 years)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Social Security#
Birthdate

Month Day Year
Relationship to Patient
Employer
Occupation
No. of years Employed
Spouse's Name

First Name Last Name
Relationship to Patient
Employer
Occupation
No. years Employed
Social Security#
Birthdate

Month Day Year
Work Phone

Area Code Phone Number
Insurance Information
Insured's Name

First Name Last Name
Insured Soc.Sec.#
Insurance Company
Group No.
Local No.
Insurance Co.Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Do you have dual coverage?

Yes No
Insured's Name

First Name Last Name
Insured Soc.Sec.#
Insurance Company
Group No.
Local No.
Insurance Co.Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Insured's Employer

First Name Last Name
Emergency Information
Name of nearest relative not living with you

First Name Last Name
Complete Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone

Area Code Phone Number
I understand that where appropriate,credit bureau reports may be obtained.
Signature (Parent signature if minor)

Clear
Date

Month Day Year
Initials

Patient Information

Responsible Party Information

Insurance Information

Emergency Information

Medical History

Dental History