Health History Form New Patients Choose Your Look Care & Use Instructions Hygiene & Diet Instructions Common Problems Common Orthodontic Questions Glossary of Orthodontic Procedures Glossary of Orthodontic Terms New Patient Forms Health History Form Health History Form Step 1 of 6 16% Patient InformationToday's Date(Required) MM slash DD slash YYYY Referred By(Required)DentistInsuranceInternetFriend/Family MemberOtherName(Required) First Middle Last Preferred Name(Required) Patient's Birthdate(Required) MM slash DD slash YYYY Gender(Required) Male Female Address(Required) Street Address Address Line 2 City State ZIP / Postal Code Phone(Required)Email(Required) Parent's Information (Skip if Adult)Choose OneN/AFatherMotherStep ParentGuardianResponsible for AccountYesNoName First Last Address Street Address Address Line 2 City State ZIP / Postal Code PhoneEmail Social Security Number Birthdate MM slash DD slash YYYY Driver's License Number Employer Occupation Choose OneN/AFatherMotherStep ParentGuardianResponsible for Account Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneEmail Social Security Number Birthdate MM slash DD slash YYYY Driver's License Number Employer Occupation Parent's Marital StatusMarriedSinglePartneredDivorcedWidowedSeparatedPatient Live WithMotherFatherGrandparentsGuardianStep parentsN/ASiblings Emergency Contact InformationEmergency Contact's Name First Last Relation to PatientParentSpouseStep ParentGuardianNeighborFriendCoworkerOtherEmergency Contact's Phone Number Dentist InformationGeneral Dentist PhoneLocation Last Visit MM slash DD slash YYYY Orthodontic Insurance InformationInsurance Company Name Policy Holder's Name Member ID Number Group Number Insurance Company Policy Number Employer Policy Holder's Social Security Number Birthdate MM slash DD slash YYYY Insurance Company Name Policy Holder's Name Member ID Number Group Number Insurance Company Policy Number Employer Policy Holder's Social Security Number Birthdate MM slash DD slash YYYY Medical & Dental InformationWhat are the main concerns that you would like orthodontics to accomplish?Has patient ever been evaluated for orthodontics before? Yes No List any allergies Please mark if any of the following apply: Asthma Diabetes Blood Disorder Epilepsy Hepatitis Heart Problems Hemophilia Sickle Cell Glaucoma Rheumatic Fever Hearing Impairment ADD/ADHD Autism Asberger Syndrome Tuberculosis Handicaps/Disabilities Lip Sucking/Biting Clenching/Grinding Teeth Mouth Breather Nail Biting Speech Problems Thumb/Finger Sucker Tongue Thrust Used Pacifier Had primary teeth pulled Had permanent teeth pulled Is patient up to date on all immunizations? Yes No Any injuries to mouth or facial area? Yes No Has patient ever been prescribed Fosamax or bisphosphonate? Yes No Please list any medical problems patient has had: Please list all drugs patient is currently taking: I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my/ child’s medical status. 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 authorize the dental staff to preform the necessary dental services my child/ me may need. I understand that I am responsible for payment of services rendered and responsible for paying any co-payment and deductible that my insurance does not cover. I hereby authorize payment of the group insurance benefits directly to the office. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.(Required)Signature of Parent or Guardian/PatientDate MM slash DD slash YYYY CAPTCHA
