Patient Information

Keith B. Dressler, D.D.S., M.S.D.

Board Certified Specialist in Orthodontics for Children and Adults

Date

Referred By

First*

Middle

Last*

Name we should call you

Gender*

MaleFemale

Phone*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Soc. Sec. #

Birthdate*

Date

Employement/School

Email

example@example.com

Gen. Dentist*

Physician

First*

Middle

Last*

Name we should call you

Phone

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Soc. Sec. #*

Birthdate

Date

Employement/School

Email*

example@example.com

First

Middle

Last

Name we should call you

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Soc. Sec. #

Birthdate

Date

Employement/School

Email

example@example.com

Parent Marital Status*

Patient lives with*

Siblings (Names and Ages)

Financially Responsible Party #1*

Relationship to Patient*

Soc. Sec. #*

Insurance Company Name/Address/Phone.*

Group #*

ID #*

Employer Name/Address/Phone*

Financially Responsible Party #2

Relationship to Patient

Soc. Sec. #

Insurance Company Name/Address/Phone.

Group #

ID #

Employer Name/Address/Phone

What are your chief concerns regarding the patients orthodontic condition? (overbite, crowding, etc.)*

Please describe your reason for considering orthodontic treatment.*

Improved facial appearancerImproved functional healthEnhanced long term dental health

Please describe the patient’s attitude towards orthodontic treatment.*

EagerComplacentAntagonistic

Does the patient have a history of any of the following? Check when yes.

Tonsils or Adenoid Removal*

YesNo

At what age?

Allergies (if yes, please list)*

YesNo

If yes, please list.

Is the need for orthodontic treatment caused by an accident?*

YesNo

If so, please give a date and description.

Is the patient in good health?*

YesNo

Under a physician's care?*

YesNo

If so, for what reason?

Taking any medications?*

YesNo

If yes, please list.

Please note any other factors the doctor should know about the patient's health.

Is the need for orthodontic treatment caused by an accident?*

YesNo

If so, for what reason?

If yes, please list.

Please note any other factors the doctor should know about the patient's health.

Recent Dental Check Up

Date

Previous Orthodontic Treatment

Date

Previous Examination by an Orthodontist

Date

What orthodontist did the patient see?

Please note any other factors the doctor should know about the patient's dental health.

The Patient (Guardian) agrees to notify Dr. Dressler if any changes occur in their medical/health history. The Patient (Guardian) agrees to be fully responsible for the total payments of procedures performed in this office including any amounts, which are not covered by any dental insurance or other payment programs. We allow 90 days for the payment of insurance coverage thereafter it is the patient’s responsibility of payment. In the event of nonpayment of treatment cost the Patient (Guardian) agrees to be responsible for any collection fees, attorney fees, or other fees necessary to collect the Patient’s (Guardian’s) account. In the process of reviewing this information, we may find it necessary to obtain a copy of your credit through a credit-reporting agency. I authorize the release of medical and dental information to insurance carriers and to other health care providers involved in the care of this patient.

I have read and thoroughly understand the above policies of this office.

Signature of Parent or Guardian*

Clear

Date

Patient Information

PATIENT

MOTHER

FATHER

OTHER

FINACIAL INFORMATION

Medical History

Dental History

Authorization