Online Form

PATIENT DETAILS

Patient's First Name

Patient's Last Name

Nickname

Patient's Address

City

State

Zip

Gender

Home Phone

Date of birth

Age

Race

Cell Phone

School/Employer

Grade/position

Home Phone

How did you hear about our office?

Family members treated in our office

Reason for Consultation

Previous Dentist

Date of last cleaning

Has the patient been examined by an orthodontist before?

Yes No

PATIENT DETAILS

Guardian's First Name

Guardian's Last Name

Social Security Number

INSURANCE (IF APPLICABLE):
Company Name

Subscriber/Member ID

GUARDIAN #2 / INSURANCE INFORMATION
Is there a second guardian and / or additional insurance to add?

Yes No

SLEEP / AIRWAY ISSUES
Does the patient tend to be a mouthbreather?

Yes No

Does the patient snore at night?

Yes No

Does the patient seem rested in the morning?

Yes No

Is the patient often sleepy during the day?

Yes No

Has the patient seen an Ear, Nose & Throat Specialist?

Yes No

IIs the patient using a sleep apnea device?

Yes No

DENTAL/MEDICAL HISTORY
Please check if the patient has a history of the following medical conditions:
Acid Reflux

Yes No

Bone Disorders

Yes No

Cerebral Palsy

Yes No

Chronic Neck Pain

Yes No

Clicking of Jaw

Yes No

Cold Sores/Herpes

Yes No

Down Syndrome

Yes No

Endocrine Problems

Yes No

Emotional Disorders

Yes No

Heart Condition

Yes No

Immune Problems

Yes No

Kidney Problems

Yes No

Low Blood Pressure

Yes No

Muscular Disorders

Yes No

Nervous Disorders

Yes No

Organ Transplant

Yes No

Painful Chewing

Yes No

Periodontal Problems

Yes No

Prolonged Bleeding

Yes No

Rheumatic Fever

Yes No

Sinus Problems

Yes No

Do your gums bleed when you brush?

Yes No

Is the patient seeing any other dental specialists?

Yes No

Any dental restorations needing to be completed?

Yes No

Have there ever been any injuries to the face, mouth or chin?

Yes No

Have you ever lost or chipped any teeth?

Yes No

Do you have any pain or soreness around your face, neck or back?

Yes No

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

Yes No

Is the patient currently pregnant?

Yes No

Have adenoids been removed?

Yes No

Have tonsils been removed?

Yes No

Currently taking any medications?

Yes No

Are antibiotics necessary prior to treatment?

Yes No

Any diseases or problems not mentioned above?

Yes No

Please check if the patient has, or ever had, any of the following habits?
Cheek, tongue or lip biting

Yes No

Clenching Teeth

Yes No

Fingernail Biting

Yes No

Grinding Teeth

Yes No

Tongue Sucking

Yes No

Thumb Sucking

Yes No

Tongue Thrusting

Yes No

SIGNED CONSENT
I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status.
I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate orthodontic treatment on the above-named patient.
I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.
Typed Name/Signature

Relationship to Patient

If someone other than the parent(s) or guardian(s) listed above will be bringing the patient to appointments, please list here:

By submitting this form you agree to the above mentioned consent statement

Ph: 916.965.7036 | 6600 Mercy Court Suite 220, Fair Oaks, CA 95628 |

PATIENT DETAILS

PATIENT DETAILS

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