Step 1 of 7 - Patient Information 0% About the PatientToday's Date* MM slash DD slash YYYY Is the patient an Adult or Child* Adult Child Male or Female* Male Female Age Marital Status*SingleMarriedDivorcedWidowedSeparatedDomestic PartnerDate of Birth* MM slash DD slash YYYY Name* First Last Preferred Name Name Home Address* Street Address City State / Province / Region ZIP / Postal Code Child's Home Address* Street Address City State / Province / Region ZIP / Postal Code Name of School Home Phone*Cell PhoneWork PhoneHobbies / Special InterestsEmail Address Enter Email Confirm Email Siblings Name Age Siblings Name Age Social Security Number About Your Employer Employer Occupation Number of years employed Your Dentist Your Dentist's Name Who referred you Date of your last visit with your Dentist? MM slash DD slash YYYY Who may we thank for referring you? Name Spouse / Partner / Guardian informationSpouse / Partner Name First Last Who is with the child today? First Last Relationship? Do you have legal custody?* Yes No Date of Birth* MM slash DD slash YYYY Father's Name First Last Work PhoneCell PhoneFather's Employer Employer Mother's Name First Last Work PhoneCell PhoneMother's Employer Employer Email Address Enter Email Confirm Email Home Phone*Cell PhoneWork / Job Information Employer Occupation Number of years employed Work Phone Responsible Party Information* First Last Billing Address* Street Address City State / Province / Region ZIP / Postal Code Home Phone*Cell PhoneWork PhoneEmergency Contact* First Last Relationship to Patient* Home Phone*Cell PhoneWork Phone Dental InsurancePrimary Insurance Name* First Primary Insurance Address Street Address City State / Province / Region ZIP / Postal Code Primary Insurance Phone*Group / Policy Number* Insured's Name* First Last Relationship to Patient* Insured's Date of Birth* MM slash DD slash YYYY Insured's Employer Insured's Social Security Number* Do you have Orthodontic Coverage? Yes No Don't know Do you have Secondary Dental Insurance* Yes No Secondary Insurance Name* First Secondary Insurance Address Street Address City State / Province / Region ZIP / Postal Code Insurance Phone*Group / Policy Number* Insured's Name* First Last Relationship to Patient* Insured's Date of Birth* MM slash DD slash YYYY Insured's Employer Insured's Social Security Number* Do you have Orthodontic Coverage? Yes No Don't know Dental HistoryWhy have you come to the Orthodontist today?Why did you bring this child to the Orthodontist today?Have you ever had serious / difficult problem associated with previous dental work? yes no Has the child ever had serious / difficult problem associated with previous dental work? yes no Are you currently in any pain? yes no Is the child currently in any pain? yes no Your dental health is: Good Fair Poor The child's dental health is: Good Fair Poor Have you ever had pain or tenderness in the jaw joint (TMJ/TMD)? yes no Has the child ever had pain or tenderness in the jaw joint (TMJ/TMD)? yes no Does the child brush daily? yes no Do you like your smile? yes no Do your gums ever bleed? yes no How many times a week do you floss? How many times a day do you brush? What type of toothbrush bristles do you use? Soft Medium Firm Does the child floss daily? yes no Does the child have thumb or finger sucking habits? yes no Does the child suck or bite their lip? yes no Does the child bite their nails? yes no Does the child have any nusing bottle habits? yes no Medical HistoryIs the child under the care of a physician? yes no Child's physician's name First Last Child's physician's phone numberPlease list any drugs the child is presently taking.Please list any drugs the child is allergic to.Do you have a physician? yes no Physician's name First Last Physician's phone numberAre you under the care of a physician? yes no If under a physicians's care, please explain.Are you taking any perscription drugs? yes no Please list all perscription or over the counter drugs and dosage taken.Women onlyAre you taking birth control pills? yes no Are you pregnant? yes no If pregnant, how many weeks? Are you nursing? yes no If under a physicians's care, please explain.Please check the box is you are allergic to any of the following? Aspirin Codine Latex Penicillin Erythromycin Tetracycline Other Please list Health HistoryDo you wear a Prosthesis?* yes no Have you ever had a Heart Attack?* yes no Have you ever had Cancer?* yes no Have you ever been diagnosed with Diabetes ?* yes no Have you ever had Rheumatic Fever?* yes no Have you ever been diagnosed with HIV/AIDES?* yes no Have you ever been diagnosed with Hemophilia?* yes no Have you ever had Asthma?* yes no Have you ever had Hepatitis?* yes no Have you ever had Tuberculosis?* yes no Have you ever had Shingles?* yes no Have you ever had Ulcer / Colitis?* yes no Have you ever had Venereal Disease?* yes no Have you ever had Heart Murmur?* yes no Have you ever had Emphysema?* yes no Have you ever had Sinus Problems?* yes no Have you ever had Scarlet Fever?* yes no Have you ever been diagnosed with a Congenital Heart Defect?* yes no Have you ever had Convulsions or Epilepsy?* yes no Have you ever had Abnormal Bleeding?* yes no Do you have any Artificial Valves?* yes no Hearing Impairment?* yes no Do you have a pacemaker?* yes no Have you had Heart Surgery?* yes no Any stays in the hospital?* yes no Any handicaps or disabilities?* yes no Any operations?* yes no Any kidney or liver problems?* yes no Mitral value prolapse?* yes no Artificial bones or joints?* yes no Do you have severe or frequent headaches?* yes no Do you have High or Low blood pressure?* yes no Drug or alcohol abuse?* yes no Have you ever had a blood transfusion?* yes no Have you ever had anemia* yes no Have you ever had Radiation therapy?* yes no Have you ever been diagnosed glaucoma?* yes no Any difficulty breathing?* yes no Any other condition you'd like to tell us?I understand the information that I have given is correct to the best of my knowledge, that it will be held in strictest confidence, and it is my responsibility to inform this office of any changes to my medical status.Electronic Signature* First Last Date* MM slash DD slash YYYY Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.PhoneThis field is for validation purposes and should be left unchanged.