Welcome to the Orthodontist

Patient Information
Today's Date
Patient's Name*

First NameMiddle NameLast Name
Gender

MaleFemale
Date of Birth

MonthDayYear
Patient's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
1st Parent's Name
Email*
example@example.com
Cell Phone #*

Area CodePhone Number
Occupation
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2nd Parent's Name
Email
example@example.com
Cell Phone #

Area CodePhone Number
Occupation
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who can we thank for referring you to us?
Previous Dentist Name
Date of last dental appointment
Responsible Party Information
Name
Relationship to Patient
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell #

Area CodePhone Number
Email
example@example.com
Birthdate
Employer
Primary Dental Insurance Information
Insured's Name
Birthdate

MonthDayYear
Date
Group #
Insurance Company
Insurance Company Phone #

Area CodePhone Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured Employer Name
Upload Image of front of insurance card

Browse Files

Cancelof
Upload image of back of Insurance card

Browse Files

Cancelof
Secondary Dental Insurance Information
Insured's Name
Birthdate

MonthDayYear
Date
Group #
Insurance Company
Insurance Company Phone #

Area CodePhone Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured Employer Name
It is important that I know about your medical and dental history. These facts have a direct bearing on your dental health. This information is strictly confidential and will not be released to anyone.

Thank you for taking the time to completely fill out this questionnaire.
Health
Physician Name
Phone Number

Area CodePhone Number
Is your child under the care of, or being treated by a physician now?

YesNo
If so, for what reason?
Does your child have regular medical check-ups?

YesNo
If so, how often?
Is your child taking any medications?

YesNo
If so, what?
Is your child allergic to anything that you know of?
Foods?
Medications?
Does your child bruise easily?
Have frequent nosebleeds?
Has your child ever bled excessively after a cut or injury?
Has a dentist or physician warned you about giving your child any specific drug or medication?
If so, what?
Has your child ever been given local anesthesia (Novocain)?
Were there any unfavorable reactions to this?
Has your child ever been in a hospital overnight?
Why?
Were there any complications?
Does your child have any of the following illnesses?

Does your child have any of the following illnesses?

	Yes	No
Rheumatic Fever
Heart Disease
Asthma
Lung/Respiratory Disease
Seizure Disorder
Kidney Disease
Heart Murmur
Diabetes
Nervous/Emotional Disorder
Mumps
Measles
Chicken Pox
Liver Disease

Dental
Is this your child's first visit to a dentist?

YesNo
If not, when was your child examined, and how well did he/she accept treatment?
Have dental x-rays been taken of your child?*

YesNo
If yes, when?
How often are your child's teeth brushed?
Are they brushed after meals?
Has your child had fluoride of any kind (supplements, vitamins, in the water)?
Has your child had fluoride applications to his/her teeth?
If so, when?
Does your child use a toothpaste that contains fluoride?
When did your child completely give up the bottle?
Does your child have any of the following habits?

Breathes through mouthTongue habitBites fingernailsSucks thumb or fingersBites or Sucks lips
Please write any additional remarks that may be helpful in rendering care to your child.
Agree to Terms

The signature of a parent or guardian affixed below authorizes the completion of all agreed upon necessary dental services.
Signature

Clear
Date
Relationship to Child
Should be Empty:

Patient Information

Responsible Party Information

Health

Dental