New Patient Information and Health History

Save time by filling out your registration and health history information online! Take a few minutes to fill out this confidential form, click the "Submit Form" button at the bottom, and your information will be sent to our office with secure encryption. We will already have your information when you arrive for your first appointment.

This web site is compliant with the Health Insurance Portability and Accountability Act (HIPAA). All of your personal health information is confidential, and will not be shared with anyone, aside from those involved in your treatment, without your consent.
Patient Information
First Name:   Nickname:
Last Name:   Email:
Home Phone:   Mobile Phone:
         
Address:   City:
State:   Zip:
Birthdate:   Gender:
Spoken Language:
Please list the names of any friends or family currently in our practice:
Please list any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
If not listed above, enter their name here:
We love to connect with our patients on FaceBook. Are you on FaceBook?
 Yes
Financial Party Information
Patient and Financial Party are the same
First Name:   Last Name:
Relationship:   Email:
Primary Phone:   Other Phone:
         
Address:   City:
State:   Zip:
Birthdate:   SSN/ID:
Occupation:   Employer:
Work Phone:   Length of Employment:
Insurance
Do you have insurance that covers orthodontics? Yes If so, fill in the following insurance info:
Insurance Company 1:
If not listed above, enter the name here:   Phone:
Insured's Name:   SSN/ID:
Group Number:      
Insurance Company 2:
If not listed above, enter the name here:   Phone:
Insured's Name:   SSN/ID:
Group Number:      
Medical History
List any medications you are taking:
List any medications you are allergic to:
List any major illness you have:
List any operations you have had:
List any serious accidents you have been in:
Please select YES if the patient has had any of the conditions listed below either now or in the past:
Abnormal bleeding/Hemophilia YesNo Hepatitis/Liver Problems YesNo
Anemia YesNo Herpes YesNo
Arthritis YesNo High Blood Pressure YesNo
Asthma or Hayfever YesNo HIV / Aids YesNo
Bone Disorders YesNo Kidney Problems YesNo
Congenital Heart Defect YesNo Nervous Disorders YesNo
Diabetes YesNo Pneumonia YesNo
Epilepsy YesNo Radiation/Chemotherapy YesNo
Gastrointestinal Disorders YesNo Rheumatic Fever YesNo
Heart Problems YesNo Tuberculosis YesNo
Heart Murmur YesNo Tumor or Cancer YesNo
Other medical conditions:
Dental History
Dentist Name:
If not listed above, enter their name here:
Checkup Frequency: Last Dental Visit:
Has the patient had an orthodontic consultant or treatment? Yes
 If so, when?
Who provided the orthodontic consult or treatment?
What is the patient's main orthodontic concern?
Please select YES if the patient has had any of the conditions listed below either now or in the past:
Apprehensive about dental care? YesNo Speech problems/therapy? YesNo
Are you presently in any dental pain? YesNo Snores during sleep? YesNo
Have you had any unfavorable reaction to dentistry? YesNo Frequent headaches? YesNo
Any missing or extra permanent teeth? YesNo Neck/shoulder pain? YesNo
Injury to face, jaw, teeth, or mouth? YesNo Brush teeth daily? YesNo
Do your gums bleed when you brush? YesNo Floss teeth daily? YesNo
Oral habits (thumb/finger sucking, lip/nail biting)? YesNo Flouride treatments? YesNo
Are you a mouth breather? YesNo Frequently chew gum? YesNo
Discomfort from teeth or gums? YesNo Requires premedication? YesNo
Pain, tenderness or noise in either jaw? YesNo Female Patients only:  
Grind or clench teeth? YesNo Are you pregnant? YesNo
Frequent sore throats? YesNo Has menstruation started? YesNo
 
In the future, please advise the doctor of any changes in your medical or dental health while under the care of this office.
I Agree

To the best of my knowledge, the information provided on this Information and Health History form are complete and correct. I understand that it is my responsibility to inform the doctor if there are any changes in the future. I authorize the release of medical and dental information to the insurance carriers and to other health care providers involved in my care. Additionally, I authorize payments directly to this office for insurance benefits otherwise payable to me for services rendered. (Credit reports are routinely obtained to assist us in payment plans)
Authorizer:

Enter the full name of the authorizer
 
By clicking the "SUBMIT" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

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