Online Forms

Patient Details

Name

Last Name

Patient's Address

City

State

Zip Code

Gender

Home Phone

Date of birth

Age

Race

Cell Phone

School/Employer

Grade/position

Work phone

How did you hear about our office

Family members treated in our office

Reason for Consultation

Previous Dentist

Has the patient been examined by an orthodontist before?

YesNo

Guardian #1 / Insurance Information

SelfSpouseFatherMotherStepparentOther

Guardian's First Name

Guardian's Last Name

State

Zip

Employer

Work Phone

Date of Birth

Social Security Number

Cell Phone

Company Name

Phone

Subscriber/Member ID

Please upload an image of the FRONT of your insurance card

Please upload an image of the BACK of your insurance card

Guardian #2 / Insurance Information

Is there a second guardian and / or additional insurance to add?

YesNo

Sleep / Airway Issues

Does the patient tend to be a mouthbreather?

YesNo

Does the patient seem rested in the morning?

YesNo

Has the patient seen an Ear, Nose & Throat Specialist?

YesNo

Does the patient snore at night?

YesNo

Is the patient often sleepy during the day?

YesNo

Dental/Medical History

Please check if the patient has a history of the following medical conditions:

Acid RefluxAnemiaAutismClicking of JawDiabetesEmotional DisordersHeart ConditionImmune ProblemsMuscular DisordersOsteoporosisProlonged BleedingSeizuresADHD/ADDArthritisBone DisordersChest PainJaw PainEpilepsyHepatitisKidney ProblemsNervous DisordersPainful ChewingSinus ProblemsAIDS/HIVAsthmaCancerCold Sores/HerpesEndocrine ProblemsHeadachesEar PainLow Blood PressurePeriodontal ProblemsTMJ ProblemsHigh Blood Pressure

Do your gums bleed when you brush?

YesNo

Is the patient seeing any other dental specialists?

YesNo

Any dental restorations needing to be completed?

YesNo

Have there ever been any injuries to the face, mouth or chin?

YesNo

Have you ever lost or chipped any teeth?

YesNo

Do you have any pain or soreness around your face, neck or back?

YesNo

Is any part of your mouth sensitive to temperature or pressure?

YesNo

Is the patient currently pregnant?

YesNo

Currently taking any medications?

YesNo

Are antibiotics necessary prior to treatment?

YesNo

Seasonal or Food Allergies

YesNo

Drug Allergies

YesNo

Any diseases or problems not mentioned above?

YesNo

Please check if the patient has, or ever had, any of the following habits?

Cheek, tongue or lip bitingGrinding TeethTongue ThrustingClenching TeethTongue SuckingFingernail Biting Thumb Sucking

Signed Content

I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status.

I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate orthodontic treatment on the above-named patient.

I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.

Typed Name/Signature

Relationship to Patient

Date

If someone other than the parent(s) or guardian(s) listed above will be bringing the patient to appointments, please list here:

By submitting this form you agree to the above mentioned consent statement

Thank you! We will connect with you shortly.

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Patient Details

Guardian #1 / Insurance Information

Please upload an image of the FRONT of your insurance card

Please upload an image of the BACK of your insurance card

Guardian #2 / Insurance Information

Sleep / Airway Issues

Dental/Medical History

Signed Content

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Patient Details

Guardian #1 / Insurance Information

Please upload an image of the FRONT of your insurance card

Please upload an image of the BACK of your insurance card

Guardian #2 / Insurance Information

Sleep / Airway Issues

Dental/Medical History

Signed Content

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