meadvilleorthodontics.com- Patient Information

Patient Information
Name

First Name Middle Name Last Name
Nickname
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Cell/ Other Phone
Email
example@example.com
Birth Date

Month Day Year
Gender

Male Female
SSN# (U.S.only)
If patient is a minor, parent's /guardian's name

First Name Last Name
Referred By:
Responsible Party Information
Name

First Name Last Name
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
Cell/Other Phone
Email
example@example.com
If patient is under 18, please complete this section.
Previous Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
SSN# (U.S. only)
Birth date

Month Day Year
Relationship to Patient
Employer
Occupation
Number of Years Employed
Spouse's Name

First Name Last Name
Relationship to Patient
Employer
Occupation
Number of Years Employed
SSN# (U.S. only)
Birth date

Month Day Year
Home Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Cell/ Other Phone
Email
example@example.com
Dental Insurance Information
Primary Insurance Information
Insured's Name

First Name Last Name
Insured Person's Date of Birth

Month Day Year
Insured's SSN# (U.S. only)
Insurance Company
Group Number
Local Number
Insurance Company Address
Phone Number

Area Code Phone Number
Do yo have dual coverage?
Secondary Insurance Information
Insured's Name

First Name Last Name
Insured's SSN# (U.S. only)
Insured Person's Date of Birth

Month Day Year
Insurance Company
Group Number
Local Number
Insurance Company Address
Phone Number

Area Code Phone Number
Emergency Information
Name of the nearest relative not living with you

First Name Last Name
Phone Number

Area Code Phone Number
Complete Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Medical History
Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.
Physician Name

First Name Last Name
Date of Last Visit

Month Day Year
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please check any of the following which apply to you, and add any relevant comments.
Are you taking any medication?
Are you allergic to any medication?
Do yo have a history of any major illness?
Have you had any major operations?
Have you ever been involved in a serious accident?
Please check any of the following that you have had or currently have:
Abnormal bleeding/Hemophilia Anemia Arthritis Asthma or Hay fever Bone Disorders Congenical Heart Defect Diabetes Dizziness Epilepsy Gastrointestinal Disorders Heart Problems Heart Murmur Hepatitis/Liver Problems Herpes High Blood Pressure HIV/Aids Kidney Problems Pneumonia Neurvous Disorders Prolonged Bleeding Radiation/Chemotherapy Rheumatic Fever Tuberculosis Tumor or Cancer
Are there any medical conditions we have not discussed that you feel we should be aware of?
Do you use tobacco?

Yes No
For Women: Are you pregnant?

Yes No
Dental History
Dentist Name

First Name Last Name
Last date of visit:

Month Day Year
What concern you most about your teeth?

Please check any of the following which apply to you and add any relevant comment:

Yes

Please add any relevant Comment?

Are you presently in any dental pain?

Have you ever experienced any unfavorable reaction to dentist?

Have you ever lost or chipped any teeth?

Have there been any injuries to face, mouth or teeth?

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

Do your gums bleed when you brush?

Do you have any type of thumb or tongue habit?

Are you a mouth breather?

Have you ever seen an orthodontist?

If yes, who?
When?
What is our attitude toward receiving orthodontic treatment?
How did they feel about the result?

Yes

Please add any relevant Comment?

Has anyone in your family received orthodontic treatment?

Do your teeth or jaws ever feel uncomfortable when you awake in the morning?

Are you aware of your jaws clicking or popping?

Are you aware of clenching your your teeth during the day?

Have you ever been told that you grind your teeth?

Do you have 'tension' headaches?

Have you ever experienced chronic ringing in your ears?

Do you have any extra or missing teeth?

Are you happy with the way your smile looks? If not what would you change?

Over office is HIPPA compliant and is committed to meeeting or exceeding the standards of infection control mandated by OSHA, the CDC , and the ADA. I authorize the dental staff to perform the necessary orthodontic services my child or my self may need.
Signature

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Patient Information

Responsible Party Information

Dental Insurance Information

Emergency Information

Medical History

Dental History