mittorthodontics.com-ORTHODONTIC PATIENT INFORMATION

ORTHODONTIC PATIENT INFORMATION
WELCOME TO OUR OFFICE
The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examinathon in our office, In order for the onthodontist to thoroughly diagnose any condition, he must have accurate background and health information on which to base his decisions. This informaion, important for your health, is confidential, Please circle the appropriate responses where indicated.
PATIENT INFORMATION
Name

First Name Last Name
Home Phone

Area Code Phone Number
Cell Phone
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Social Security#
Birth date

Month Day Year
Age
Sex
Marital Status
Occupation/ Name of School
Teacher
Grade
Employer
Business Phone

Area Code Phone Number
Family Dentist

First Name Last Name
How did you hear about our office?
Family Physician

First Name Last Name
FAMILY STATUS
Patient Living with
Father's Name

First Name Last Name
Mother's Name

First Name Last Name
Siblings?

Yes No
Number Brothers
Number Sisters
INSURANCE INFORMATION
Is patient covered by dental or orthodontic insurance?

Yes No
Lifetime Max
Percent Payable
Policy Holder
Policy Holders Social Security #
Employer
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Birth Date

Month Day Year
Relation to Patient
Insurance Company Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Group No.
Contract No.

Area Code Phone Number
Occasionally information is shared with a family dentist or other specialists. By providing us your email address, we can share this information with you.
Email
example@example.com
PERSON RESPONSIBLE FOR ACCOUNT
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How long at this address?
Previous Address (if less than 2 years)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone

Area Code Phone Number
Cell Phone
May we call you at your job?
Work Phone

Area Code Phone Number
Driver's License No:
Social Security No.
Birth Date
Relation to Patient
Marital Status
Sex
Employer
Occupation
No. of Years Employed
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
SPOUSE/OTHER PARENT INFORMATION
Name

First Name Last Name
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
May we call your job?
Cell Phone
Relationship to Patient
Employer
Occupation
No. of Years Employed
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Social Security No.
Birth Date

Month Day Year
SECOND INSURANCE CARRIER INFORMATION
Is patient covered by dental or orthodontic insurance?

Yes No
Lifetime Max
Percent Payable
Policy Holder
Policy Holders Social Security #
Employer
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Birth Date

Month Day Year
Relation to Patient
Name of Ins. Co.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Group No.
Contract No.

Area Code Phone Number

	Yes/No	If yes, Explain
Seasonal grasses
Food
Drugs
Other

	Yes/No
Were the patient’s teeth cleaned?
Is the patient aware of any orthodontic problem?
Are there any untreated or active cavities ?
Has the patient visited another orthodontist?