PATIENT CONTACT INFORMATION
Birth Date:
Gender: Male Female
RESPONSIBLE PARTY INFORMATION
Residence Address: Same as above
Mailing Address (if different):
Birth Date:
Employment information:
DENTAL INSURANCE INFORMATION
No Dental Insurance
Birth Date:
Check if you have dual coverage
Birth Date:
EMERGENCY CONTACT
PATIENT'S MEDICAL HISTORY
Currently Taking Medication:
Allergic to Medication:
History of Major Illness:
History of Major Operations:
ADHD
Autism or Asperger's Syndrome
Bone Disorders
Diabetes
Heart Condition
Hepatitis/Liver Problems
HIV/Aids
Psychological, Behavioral or Developmental Issues
Must pre-medicate With an Antibiotic Before Having Teeth Cleaned
PATIENT'S DENTAL HISTORY
Date of Last Visit:
Is the patient scheduled for the above procedures? YesNoNA
Please explain any of the following which apply to the patient with relevant comments.
ABOUT TODAY'S VISIT
If today's evaluation reveals a need for treatment, what option are you most interested in? (Invisalign, Invisalign Teen, Metal or Clear Braces, etc.
What is your number one concern with your smile?
What motivated you to come in at this time?
How did you first hear about our office?
What is your previous experience seeing an orthodontist?
Are there medical, allergy, psychological or special needs issues our office should be aware of?

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