• PATIENT INFORMATION

  • Date:*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Gender:*
  • Birthdate:*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • RESPONSIBLE PARTY INFORMATION

  • Birthdate:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Birthdate:
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • ORTHODONTIC INSURANCE INFORMATION

  • Date of Birth:
     / /
    2 digit month, 2 digit day, 4 digit year
  • Do you have dual coverage?*
  • Date of Birth:
     / /
    2 digit month, 2 digit day, 4 digit year

  • EMERGENCY INFORMATION

  • Legendary Smiles Confidential Patient Medical and Dental History

  • Date of Birth:*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Has patient ever been under the extended care of a physician or had any surgeries?*
  • CHECK ANY OF THE FOLLOWING FOR WHICH THE PATIENT HAS BEEN TREATED
  • Is the patient currently on any medications?*
  • Is the patient allergic to any food or medicines?*

  • DENTAL AND ORTHODONTIC HISTORY

  • Were any x-rays taken at patient's last dental visit?*
  • Has patient had any problems with dental exams or treatment in the past?*
  • Has patient had any cavities in the past?*
  • Does patient brush their teeth daily?*
  • Does patient currently take a fluoride supplement tablet, gels, rinses, etc.?*
  • Has patient ever received local anesthetic?*
  • Has patient ever had sealants placed?*
  • Does patient floss their teeth daily?
  • If applicable: Has parent been diagnosed with tooth decay in past two years?*
  • Has patient experienced any trauma to the teeth? (falls, blows, chips, etc.)*
  • Has patient ever sucked thumbs or fingers?*
  • Does patient have speech problems?*
  • Has patient ever been informed of any extra or missing teeth?*
  • Has patient ever had a previous orthodontics in the past?*
  • Does patient have any pain in their jaws?*
  • Does patient have any popping or clicking of the jaw joint?*

  • I certify that the above information is complete and accurate.

  • Date:*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Please read the following:

  • Image field 156
  • Image field 157

  • LEGENDARY SMILES

    ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

    **You May Refuse To Sign This Acknowledgment**

  • I, have received a copy of this office's Notice of Privacy Practices.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Patient Communication Form

  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • How would you like us to communicate with you?

    Our orthodontic office sends appointment reminders, information about treatment, payment and insurance, and other communications including but not limited to newsletters, events, etc. Please tell us how you would like us to communicate with you.

  • Check or complete all that apply (please fill out completely):
    Rows

  • For Phone and Text Communications:

    This form is optional. You are not required to sign this form, and you do not need to sign it to receive care in our orthodontic office.

  • Format: (000) 000-0000.
  • By checking one of the boxes below, you are consenting to the following: The orthodontic practice may contact me to provide health care information such as appointment reminders and information about treatment, payment, my account or insurance, using artificial or prerecorded voice or telephone equipment that may be capable of automatic dialing. The orthodontic practice may:
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Thank you for taking the time to fill this out!

  • Should be Empty: