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General Information
Name
*
First
Middle
Last
Have you ever been evaluated for orthodontic treatment?
Yes
No
I have gone through treatment before
Are you happy with the way your smile looks?
Yes
No
My smile affects my confidence
What are the MAIN orthodontic concerns you would like to fix?
Email
*
Cell Phone
*
Home Phone
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Birthdate
*
Gender
Female
Male
Opt Out
Social Security Number
This is required to determine insurance eligibility. Please call our office if you prefer not to provide online.
What is the best method to contact you?
Call
Text
Email
When is the best time to reach you?
Please provide a specific time if needed
How did you hear about us?
*
Google / Online
Family / Friend
Social Media
Dentist
Insurance Company
Name of Person who Referred you
Marital Status
Single
Married
Divorced
Widowed
Name of Spouse
Spouse's Cell
Spouse's Employer
Employer Information
Your Occupation
If NO occupation, Please leave BLANK
Employer
Work Phone Number
DENTAL Insurance Information
Please provide Dental Insurance under which you are covered. This may be Spouse's Dental Insurance.
Do you have Dental Insurance Coverage?
Yes
No
Dental Insurance Card
Click or drag files to this area to upload.
You can upload up to 2 files.
Please take a photo of the FRONT and BACK of your insurance card. You don't have to fill out insurance info if you upload photos!
Name of Dental Insurance
I.e. Delta, Aetna, United Concordia... If NO insurance, please leave BLANK
Do they cover orthodontic treatment?
Yes
I'm Not Sure
No
Name of Insured
Your name, if covered under your own insurance. Spouse or other's name, if covered under their insurance.
Insured's Relation to Patient
Self
Spouse
Other
Insured Date of Birth
Please provide month/day/year. If same as your DOB, please respond: Same
Insured's Employer
Employer under which policy is offered. If same as your employer, respond: Same
Dental Insurance GROUP #
Dental Insurance ID #
Dental Insurance Phone #
Dental History
Who is your Dentist (or last Dentist)?
*
If you do not have a current dentist, please respond: None
When was your last dental visit?
6 months or less
6 months to 1 year
Over 1 year
How would you describe your dental health?
Good
Fair
Poor
Have you ever had trauma to your Teeth or Jaws?
Yes
No
Please describe the injury to your teeth or jaws, including the date it happened:
Have you Ever had a Serious/Difficult problem associated with anyPrevious Dental Work?
Yes
No
Please describe previous dental problems
Have you Now, or Ever experienced Pain or Discomfort in your Jaw Joint (TMJ?)
Yes
No
Please describe pain in TMJ?
Do you have any speech problems?
Yes
No
Do you generally breathe through your mouth?
Yes
No
Medical History
This section will determine if there are any medical concerns that may interfere with orthodontic treatment
Have you EVER taken medication for Osteoporosis?
*
Yes
No
This includes Fosamax, or medications known as Bisphosphonates
Please provide Name of Medication and How it is, or was Taken
Taken by mouth, or injected by doctor
Any Artificial Bones/Joints/Heart Valves?
Yes
No
Please describe artificial bones/joints/heart valves, and dates of placement
Have you EVER been under the care of a physician for a medical condition or chronic illness?
Yes
No
Please describe the medical condition requiring a physician's care:
I.e. High Blood Pressure, or Cancer treatment, or Lymes Disease, etc...
Are you taking prescribed medications?
Yes
No
Please List your prescribed medications:
I.e. Atorvastatin (Lipitor) for Cholesterol.... or Amlodipine for BP (blood pressure), etc...
Have you ever been hospitalized for a life threatening injury / disease?
Yes
No
Please describe reason for hospitalization:
Have you ever been diagnosed with:
Hepatitis
Herpes / Fever Blisters
HIV / AIDS
Rheumatic / Scarlet Fever
Shingles
Tuberculosis
Abnormal Bleeding / Hemophelia
Anemia
Arthritis
Asthma
Cancer
Congenital Heart Defect
Diabetes
Difficulty Breathing
Emphysema
Epilepsy / Seizures
Fainting Spells
Frequent Headaches
Glaucoma
Hay Fever
Heart Murmur
High Blood Pressure
Low Blood Pressure
Kidney Problems
Liver Disease
Lupus
Mitral Valve Prolapse
Psychiatric Problems
Sickle Cell Disease / Trait
Sinus Problems
Stroke
Thyroid Problems
Ulcers
Are there any Additional Concerns you have that were not addressed above?
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