Patient Information


    Responsible Party Information

    Insurance Information

    Medical History

    Please check Yes or No. If Yes, please fill in details.

    Are you taking any medication?

    Are you allergic to any medication?

    Do you have a history of a major illness?

    Are you allergic to Nickel or Latex?

    Have you had any major operations?

    Have you ever been involved in a serious accident?

    Are you pregnant?

    Please check any of the medical conditions below that you have had or currently have.

    Abnormal Bleeding / HemophiliaAnemiaArthritisAsthma or HayfeverBone DisordersCongenital Heart DefectDiabetesDizzinessEpilepsyGastrointestinal DisordersHeart ProblemsHeart MurmurHepatitis/ Liver ProblemsHerpesHigh Blood PressureHIV+/ AIDSKidney ProblemsNervous DisordersPneumoniaProlonged BleedingRadiation/ ChemotherapyRheumatic FeverTuberculosisTumor or Cancer

    Dental History

    What concerns you most about your smile?

    Do you go for regular check-ups?

    Are you presently in any dental pain?

    Have you ever experienced any unfavorable reaction to dentistry?

    Have you ever lost or chipped any teeth?

    Have there been any injuries to face, mouth or teeth?

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

    Do your gums bleed when you brush?

    Do you have any type of thumb or tongue habit?

    Are you a mouth breather?

    Have you ever seen an orthodontist?

    Has anyone in the family received orthodontic treatment?

    How do they feel about their results?

    What is your attitude toward receiving orthodontic treatment?

    Do your teeth or jaws ever feel uncomfortable when you wake up in the morning?

    Are you aware of your jaw clicking or popping?

    Are you aware of clenching your teeth during the day?

    Have you ever been told that you grind your teeth?

    Do you have “tension” headaches?

    Have you ever experienced chronic ringing in your ears?

    Are you aware that some appointments will be during school/work hours?

    Benefits of Orthodontics:

    Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment.

    I have read and understand the above paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history.

    1. This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services. I certify that all information provided is accurate and understand that the information will be relied upon for granting credit and providing orthodontic services. I hereby authorize this office to release all information necessary to obtain information on credit.

    2. I understand that I am financially responsible for payment of services rendered and also responsible for charges not covered by or paid by my insurance for whatever reason. I authorize payment directly to the orthodontic office of any group insurance benefits otherwise payable to me. I understand that I am financially responsible for any charges not covered by this authorization. I hereby authorize this office to release all information necessary to secure payment or benefits.

    3. I have read and understand all questions above. I certify that I have the information I have provided is correct and accurate to the best of my knowledge. I will not hold this orthodontic office, the orthodontist or any member of the staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes to the patient's medical or dental history, it will be my responsibility to inform this practice.

    I Agree.    By checking "I Agree" and clicking "Submit" below, you agree to the privacy policy, disclaimer, and all of the terms and conditions listed above.

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