Health History Form

Health History Form
Submit Your Health History Form Online to Your Orthodontist

Save time and fill out your registration and health history information online! Fill out this confidential form, click the "Submit Form" button at the bottom, and your information will be sent to our office with secure encryption.
We will have your information when you arrive for your first appointment. You will need to provide a signature at the office to verify that the information you submitted online is accurate.
Patient Information
Name *

First Name Middle Name Last Name
Home Address *

Street Address

Street Address Line 2

City State

Zip Code Country
Home Phone *

Area Code Phone Number
Work Phone

Area Code Phone Number
Cell/Other Phone

Area Code Phone Number
Email Address *
example@example.com
Birthdate *

Month Day Year
Gender *

Male Female
How did you hear about our office? *
Dental Insurance Information
Dental Insurance Company
Employer
Member or Subscriber ID Number
Group Number
Relationship to Patient *
Insurance Phone Number

Area Code Phone Number
Employee Name
Occupation
Employee Birthdate *

Month Day Year
Insurance Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.
Initial Here
I have a second dental plan

If you have second dental plan, please fill this fields
ID of secondary dental insurance
Name of Policy Holder
Relationship to Patient
DOB
Group Number
Employer
Responsible Party Information

If patient is under 18, please complete this section.
Full Name *

First Name Last Name
Relationship to Patient *
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Employer *
Occupation
Spouse's Name
Medical History *
Are there any medical conditions we have not discussed that you feel we should be aware of? Please describe any major health issues. *
Do you have any allergies? If so, please explain. *
Please check any of the following that you have had or currently have: *

Abnormal bleeding/Hemophilia Congenital Heart Defect Diabetes Heart Problems Heart Murmur Hepatitis/Liver Problems HIV/Aids Radiation/Chemotherapy Rheumatic Fever Tumor or Cancer Sleep apnea Snoring issues Trouble sleeping Convulsions/Epilepsy Allergies Bleeding problems of any kind Premedication before dental visits History of cancer Any operations Any stays in hospital Grind/clench teeth Hearing Impairment Jaw Joint pain (TMJ) Arthritis Headaches None of the above are applicable
What medications are you taking? *
Have you had possible exposure to TB, hepatitis, AIDs or any other contagious disease? *
Have you ever smoked? *

Yes No
Dental History
Dentist *
Dentist Phone Number

Area Code Phone Number
Date of Last Visit *

Month Day Year
Date
Date of Last Cleaning

Month Day Year
Date
Have you ever lost or chipped any teeth?

YES NO
Have there been any injuries to face, mouth or teeth?

YES NO
Do you have any type of thumb or tongue habit?

YES NO
Have you ever seen an orthodontist?

YES NO
If yes, who?
When?

Month Day Year
Date
What is your feeling about receiving orthodontic treatment?
Has anyone in your family received orthodontic treatment?

YES NO
Are you aware of your jaws clicking or popping?

YES NO
Are you aware of clenching your teeth during the day?

YES NO
Have you ever been told that you grind your teeth?

YES NO
What concerns you most about your teeth? *
KIDS SECTION
Do you have a nickname?
What are your hobbies/sports you play?
What school do you attend?
By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

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Health History Form

Patient Information

Dental Insurance Information

I have a second dental plan

Responsible Party Information

Dental History

KIDS SECTION