Patient Forms

General Patient Information

Responsible Party Information

SingleMarriedSeperateDivorcedWidowed

Dental Insurance Information

Primary Insurance

YesNo

Secondary Insurance

Emergency Information

Medical/Dental History

MaleFemale

If patient is a Child

Brothers and Sisters

Each of the following questions must be checked YES or No, whichever correctly describes the PATIENT'S present or past health status

Do you have any current or past health problems?
YesNo
Are you currently or were you previously under a physician's care for anything other than childhood disease?
YesNo
Have you ever been hospitalized ?
YesNo
Are there any medications being taken on a regular basis (including nonprescription)
YesNo
Are you allergic or sensitive to anything?
YesNo
Do you have or have you ever had any face, mouth, or teeth injuries?
YesNo
Why do you have difficulty breathing through your nose?
YesNo
Do you play a musical instrument with a mouthpiece?
YesNo
Have you had any previous orthodontic consultation or treatment?
YesNo


YesNo
YesNo
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YesNo
YesNo
YesNo
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YesNo
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YesNo
YesNo
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YesNo
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YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo

What concerns brought you to our office, and what changes would you like to see as a result of orthodontic treatment?

Do you have any explanation or additional information about any disease,conditions, or problem not listed above that you think we should know about or see as a result of orthodontic treatment?

We encourage you to contact us with any questions or comments you may have. Please call our office or use the quick contact form below.

CONTACT US