supersmilevegas.com - Patient Information

Patient Information
Items marked with asterisk (*) must be completed.
Name*

First NameMiddle NameLast Name
I prefer to be called (Nickname)
Gender

MaleFemale
Birth date*

MonthDayYear
Date
Whom may we thank for referring you to our office?*
Other family members seen by us-
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Cell Phone*
Please enter a valid phone number.
School/Employer
Parent I (minors only)
Full Name

First NameMiddle NameLast Name
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent II (minors only)
Full Name

First NameMiddle NameLast Name
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Responsible Party Information | If Different From Patient
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SSN*
Email*
example@example.com
Cell Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Dental Insurance Information
Insured's Name
Insurance Name
Employer Name
Group Number/ ID Number
Phone Number
Please enter a valid phone number.
Claims Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Information
Name of the nearest relative not living with you
Complete Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Please enter a valid phone number.
Medical History
Physician
Date of Last Visit

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Please answer 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 you have a history of any major illness?
Have you ever been involved in a serious accident?
Have you had any major operations?
Please select any of the following that you have had or currently have:

Abnormal bleeding/HemophiliaAnemiaArthritisAsthma or Hay feverBone DisordersCongenital Heart DefectDiabetesDizzinessEpilepsyGastrointestinal DisordersHeart ProblemsHeart MurmurHepatitis/Liver ProblemsHerpesHigh Blood PressureHIV/AidsKidney ProblemsPneumoniaNervous DisordersProlonged BleedingRadiation/ChemotherapyRheumatic FeverTuberculosisTumor or Cancer
Are there any medical conditions we have not discussed that you feel we should be aware of?
Dental History
General Dentist
Date of Last Visit

MonthDayYear
Date
What concerns you most about your teeth?
Please answer any of the following which
apply to you.
Are you presently in any dental pain?

YesNo
Have you ever lost or chipped any teeth?

YesNo
Have you ever experienced any unfavorable reaction to dentistry?

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

YesNo
Is any part of your mouth sensitive to temperature?

YesNo
Is any part of your mouth sensitive to pressure?

YesNo
Do you have any type of thumb or tongue habit?

YesNo
Are you a mouth breather?

YesNo
Have you ever seen an orthodontist?

YesNo
If yes, who?
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?

YesNo
Are you aware of your jaws clicking or popping?

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

YesNo
Have you ever been told that you grind your teeth?

YesNo
Do you have 'tension' headaches?

YesNo
Have you ever experienced chronic ringing in your ears?

YesNo
Release and Waiver
I authorize release of any information regarding treatment to my dentist and/ or insurance company.
Acknowledge by initialing Type a label*

I authorize SuperSmile Orthodontics to bill insurance and accept payment for services rendered.
Acknowledge by initialing Type a label*

I certify that the above information is correct and accurate to the best of my knowledge. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in completing this form. I will notify the office of any changes regarding this form
Signature*

Clear
Should be Empty:

Patient Information

Parent I (minors only)

Parent II (minors only)

Responsible Party Information | If Different From Patient

Dental Insurance Information

Emergency Information

Medical History

Dental History

Release and Waiver