Registration Information

Prefix

First and Last Name

Other (Nickname, etc)

Gender

Male

Female

Birthdate

/

Age

Address of Patient

Street

City

State

Zip

Home Phone

Cell Phone

Email

How do you prefer to be reminded of appointments?

Email

Text

Both (Email & Text)

Cell Phone Provider

Provider (Other)

Employer

Work Phone

SSN

School Attending

Hobbies/Interests

Has the patient ever been in this office before?

No

Yes

Has any other member of your family had orthodontic care at this office?

No

Yes

If yes, name and relationship to patient

Name of family dentist

Did he/she refer you to our office?

No

Yes

If no, whom may we thank for referring you to our office?

Is the patient a minor?

No

Yes

Parent/Guardian #1

Prefix

First and Last Name

Birthdate

/

Relationship to Patient

Marital Status

Street

City

State

Zip

Home Phone

Cell Phone

Email

Employer

Work Phone

SSN

Add 2nd Parent/Guardian

No

Yes

Parent/Guardian #2

Prefix

First and Last Name

Birthdate

/

Relationship to Patient

Marital Status

Street

City

State

Zip

Home Phone

Cell Phone

Email

Employer

Work Phone

SSN

Medical History

First and Last Name

Does the patient have or has he/she ever had:

Asthma or Breathing Problem

No

Yes

Heart Disease

No

Yes

Sinus Trouble/Hay Fever

No

Yes

Autoimmune Disorder

No

Yes

Hepatitis or Liver Problems

No

Yes

Tuberculosis or Lung Disease

No

Yes

Congenital Heart Defect

No

Yes

Osteoporosis

No

Yes

Other Diagnosis

Does the patient have or has he/she ever had Allergies to:

Latex

No

Yes

Local Anesthetic

No

Yes

Allergy to Other Medication

No

Yes

Other Medication Allergies

Other Allergies

No

Yes

Allergies Other

List Current Medications

Pregnant (if yes, due date)?

No

Yes

Due Date

/

Dental Insurance Information

First and Last Name

Insured Patient Date of Birth

Do you have dental insurance that may cover any part of orthodontic services?

No

Yes

Policy Holder Name

Policy Holder Date of Birth

/

Relationship to Patient

Dental Insurance Company

Dental Insurance Company Street Address

City

State

Zip

Dental Insurance Company Phone Number

Policy Holder's SSN

Policy Holder's ID

Employer

Group Number

Effective Date

/

If more than one dental insurance, is this one:

Primary

Secondary

Do you have additional dental insurance?

No

Yes

Dental Policy Holder Name

Dental Policy Holder Date of Birth

/

Relationship to Patient

Dental Insurance Company

Dental Insurance Company Street Address

City

State

Zip

Dental Insurance Company Phone Number

Policy Holder's SSN

Policy Holder's ID

Employer

Group Number

Effective Date

/

First and Last Name

Consent Signatures

By signing below, I certify that the information I have provided today is complete and accurate. I also understand that it is my responsibility to inform the office of any changes regarding my (or my child's) medical health. I authorize the dental staff to perform necessary dental services that I, or my child, may need during diagnosis and treatment.

Signature of Patient (Parent or Guardian if Minor)

Date

/

I authorize my doctor and his / her designated staff, to perform an examination, for the purpose of diagnosis and treatment planning. If medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. I hereby acknowledge that a copy of this office's Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions regarding this Notice.

Signature of Patient (Parent or Guardian if Minor)

Accept or Decline

Accept

Decline

Date

/

I permit messages to be left on my phone and/or mobile phone(s) concerning appointments, treatment, insurance, and my account.

Signature of Patient (Parent or Guardian if Minor)

Accept or Decline

Accept

Decline

Date

/