Appointment Request

Patient Information

* Patient Name: (Required)

Gender: Male Female

Birth Date:

Age:

Home Address:

City:

State:

Zip:

* Primary Phone Number:

Phone Type home cell

OK to leave message? Yes No

E-mail:

* Employer's Name:

Occupation:

Spouse / Partner Information

Spouse/Partner's Name:

Marital Status: Single Married Divorced Widowed

Birth Date:

Address (if different than patient):

City:

State:

Zip:

Primary Phone:

Phone Type: home cell

Secondary Phone:

Phone Type: home cell

Emergency Contact Information

Emergency Contact's Name:

Phone Number:

Relation to Patient:

Address:

City:

State:

Zip:

Person(s) OK to release appointment or medically-related information to:

Relation to Patient:

Insurance Information

Primary Insurance

Primary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Dental History

General Dentist:

Last Visit:

What are the main concerns you would like orthodontics to correct?

Have you visited an orthodontist before? Yes No

If yes, when:

Reason:

Have your tonsils or adenoids been removed? Yes No

Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)? Yes No

Have you ever had an injury to (select all that apply): Teeth Mouth Chin

Do your gums bleed? Yes No

Do you smoke? Yes No

Do you currently or have you ever had any of the following habits (check all that apply): Clenching/Grinding Teeth Lip Sucking/Biting Mouth Breathing Nail Biting Thumb/Finger Sucking Chewing/Eating Problem

Medical History

Are you currently being treated by a physician? Yes No

Reason:

Physician:

Last Visit:

Phone:

Do you have any allergies/sensitivities to medications or latex? Yes No

If yes, please list:

Are you currently taking any prescription or over-the-counter medications? Yes No

If yes, please list with the dosage:

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)? Yes No

Have you had any serious illnesses or operations? If yes, describe:

(Women) Are you pregnant? Yes No

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

Submitted by:

Date: