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1-800-Dentist

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Patient Referral

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If referred, by who?

Responsible Party Information
If patient is under 18, responsible party must complete this section.

Relationship to Parent

Dental Insurance Information

Insurance Phone Number

Policy Holder's Name

Policy Holder's Date of Birth (MM/DD/YYYY)

Policy Holder's Social Security # (U.S. only)

Do you have dual insurance coverage?

Yes

If you have dual coverage, please provide information on your secondary insurance below.

Insurance Phone Number

Policy Holder's Name

Policy Holder's Date of Birth (MM/DD/YYYY)

Policy Holder's Social Security # (U.S. only)

Date of Last Visit (MM/DD/YYYY)

Have you had previous orthodontic treatment?

Yes

If yes, please provide the name of your orthodontist.

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

Yes

Are you presently in any dental pain?

Yes

Do your gums bleed when you brush your teeth?

Yes

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

Yes

Do your teeth or jaws ever feel uncomfortable?

Yes

Do your jaws make any clicking or popping noises?

Yes

Do you clench your teeth during the day?

Yes

Have you ever been told that you grind your teeth?

Yes

Have you ever experienced chronic ringing in your ears?

Yes

Do you have 'tension' headaches?

Yes

Do you have any type of thumb or tongue habit?

Yes

Are you a mouth breather?

Yes

Do you have blisters or sores on your lips and/or in your mouth?

Yes

Do you have a burning sensation on your tongue?

Yes

Do you smoke cigarettes, cigars, a pipe, etc.?

Yes

Do you have sensitivity to cold, hot, and/or sweets?

Yes

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.

Are you taking any medication?

Yes

Are you allergic to any medication?

Yes

Do you have a history or any major illness?

Yes

Are you or have you ever taken Bisphosphonates for osteoporosis?

Yes

Have you ever been involved in a serious accident?

Yes

Please check any of the following that you have had or currently have:

I have the following

Abnormal bleeding/Hemophilia

Anemia

Arthritis

Artificial Heart Valves

Artificial Joints/Prosthesis

Asthma

Back Problems

Blood Disease

Bone Disorders

Chemical Dependency

Circulatory Problems

Congenital Heart Defect

Cortisone Treatments

Diabetes

Dizziness

Drug use (illegal)

Emphysema

Epilepsy

Glaucoma

Heart Problems

Heart Murmur

Hepatitis/Liver Problems

Herpes

High Blood Pressure

HIV/AIDS

Kidney Disease

Low Blood Pressure

Nervous Problems

Mitral Valve Prolapse

Pacemaker

Psychiatric Care

Radiation/Chemotherapy

Respiratory Disease

Rheumatic Fever

Scarlet Fever

Skin Rash

Special Diet

Stroke

Thyroid Problems

Tonsillitis

Tuberculosis

Tumor or Cancer

Ulcer

Venereal Disease

Are you pregnant?

Yes

Are You Nursing?

Yes

If you checked any of the above and need to describe it. Please type it on this box.

Are there any medical conditions we have not asked that you feel we should be aware of?

By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

Address

How did you hear about us? Please check below.

Responsible Party Information
If patient is under 18, responsible party must complete this section.

Dental Insurance Information

If you have dual coverage, please provide information on your secondary insurance below.

Dental History

Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.

Please check any of the following that you have had or currently have:

Women

Address

How did you hear about us? Please check below.

Responsible Party InformationIf patient is under 18, responsible party must complete this section.

Dental Insurance Information

If you have dual coverage, please provide information on your secondary insurance below.

Dental History

Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.

Please check any of the following that you have had or currently have:

Women

Responsible Party Information
If patient is under 18, responsible party must complete this section.