Patient Registration

Patient First Name

MI

Patient Last Name

Birth Date

Nickname

Gender

Male Female Other

Other

Patient Prefers

He She They

Address

City

State

ZIP

Social Security #

Home Phone

Cell Phone

Email

Family Dentist

Whom may we thank for referring you?

Relatives treated here

Has the patient visited an orthodontist before?

Yes No

If Yes, for what reason?

What are your main concerns?

FOR MINOR PATIENT ONLY - Who is filling in this form?

First Name

MI

Last Name

Relationship

Do you have legal custody?

Yes No

Responsible Party Information

First Name

MI

Last Name

Residence

City

State

ZIP

Mailing Address

City

State

ZIP

Primary Phone

Work Phone

Relationship to Patient

Birth Date

Social Security #

Marital Status

Employer

Occupation

# of years employed

Spouse Information

First Name

Last Name

Relationship to Patient

Social Security #

Birth Date

Primary Phone

Employer

Occupation

# of years employed

Emergency Contact Information

Name of friend or nearest relative not living with you

Primary Phone

Work Phone

DENTAL INSURANCE INFORMATION

Do you have dental insurance?

Yes No

Primary Insurance Information

Policy Holder Name

Relationship to Patient

Birth Date

Phone #

Address

City

State

ZIP

Employer

Social Security # / ID #

Dental Insurance

Phone #

Medical Insurance

Phone #

Do you have secondary insurance?

Yes No

SECONDARY DENTAL INSURANCE COMPANY

Policy Holder Name

Relationship to Patient

Birth Date

Phone #

Address

City

State

ZIP

Employer

Social Security # / ID #

Dental Insurance

Phone #

Medical Insurance

Phone #

HEALTH HISTORY

Family Physician

Is the patient under the care of a physician for any medical problems?

Yes No

If yes, for what reason

Does the patient need to premedicate prior to any dental procedure due to heart murmur or any other medical problem?

Yes No

If yes, what medicine do you premedicate with?

Please describe your current dental health

Good Fair Poor

Last dental visit

Do your gums bleed?

Yes No

Has the patient ever had any pain/discomfort in the jaw joint (TMJ/TMD)?

Yes No

Has the patient’s jaw ever made noise (pop or click) or ever locked open or closed?

Yes No

Has the patient ever had an injury to the:

Mouth Teeth Chin

Has the patient ever been evaluated for orthodontic treatment?

Yes No

What are your main concerns that you would like Orthodontics to accomplish?

HAS THE PATIENT EVER HAD ANY ALLERGIC REACTIONS TO THE FOLLOWING?

Other

MEDICATIONS

Is the patient currently taking any medications, including over-the-counter medications?

Yes No

Please list all medications the patient is currently taking below.

HAS THE PATIENT EVER HAD ANY OF THE FOLLOWING?

Heart Attack/Stroke

Yes No

High/Low Blood Pressure

Yes No

Anemia/Radiation Treatment

Yes No

Cancer/Chemotherapy

Yes No

Fever Blisters

Yes No

Asthma/Arthritis

Yes No

Heart Murmur

Yes No

Frequent Headaches

Yes No

Difficulty Breathing

Yes No

Rheumatic Fever

Yes No

Currently Pregnant

Yes No

Any Operations

Yes No

HIV/AIDS

Yes No

Psychiatric Problems

Yes No

Hospitalized for Any Reason

Yes No

Heart Surgery/Pacemaker

Yes No

Epilepsy/Seizures/Fainting

Yes No

Hepatitis

Yes No

Shingles

Yes No

Diabetes/Tuberculosis (TB)

Yes No

Blood Transfusion

Yes No

Mitral Valve Prolapse

Yes No

Drug/Alcohol Abuse

Yes No

Emphysema/Glaucoma

Yes No

Kidney Problems

Yes No

Venereal Disease

Yes No

Hearing Impaired

Yes No

Artificial Bones/Joints

Yes No

Hemophilia/Abnormal Bleeding

Yes No

Handicaps/Disabilities

Yes No

Artificial Valves

Yes No

Ulcers/Colitis

Yes No

None of the Above

Yes No

Sinus Problems

Yes No

Congenital Heart Defect

Yes No

Is there any other medical/dental condition that was not mentioned above? If yes, please list below.

Yes No

FORM COMPLETION

I understand the information I have provided is true and correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the Orthodontic Staff to perform any necessary orthodontic services that I may need. I understand that where appropriate, credit bureau reports may be obtained.

Signature of Patient, Parent or Legal Guardian

Clear

Clear

Date

IF PATIENT IS A MINOR

Form signed by

Relationship to Patient