Patient Information
Top of Form
Patient’s name: ______Sex: r M
Bottom of Form
First MI Last r F
Nickname/Preferred name you would like to be called: ______
Address: ______
Street City Zip
Birth Date: ____/____/____ Age: _____
Main Phone(**): ______Cell Phone: ______
(**) This is the # we contact for HouseCalls appointment reminders, billing, etc.
Whom may we thank for referring you to our office?
How did you first hear about our office?
Please list other family members seen at this office and their relationship to this patient:
Personal Information (Child)
School:______Grade: ______
Hobbies & Interests:______
Brothers/Sisters (ages):______
Responsible Party Information
Name: ______
First MI Last
Address (if different): ______
Street City Zip
Relationship to patient: ______Marital Status: r Married r Single r Divorced r Separated r Widowed
Employer: ______Occupation: ______
Main(**) phone:______Work phone: Cell phone:______
Email address (for T.Link billing statements, appointment reminders, etc.):
Spouse’s Name: ______
First MI Last
Relationship to patient: ______
Employer: ______Occupation: ______
Home phone:______Work phone: Cell phone:______
Patient lives with: r Both Parents Together r Both Parents Separately r Mother r Father r Adult (N/A)
Dental Insurance Information
Primary Insurance Company ______Group/Plan/Local No.
Insurance Co. Address______Phone No.
Policy Owner’s Name______Birth Date: ____/____/____ Social Security #_____-_____-_____
* Do you have dual coverage? r Yes r No If yes, complete below:
Secondary Insurance Company ______Group/Plan No.
Insurance Co. Address______Phone No.
Policy Owner’s Name______Birth Date: ____/____/____ Social Security #_____-_____-_____
Medical History
Physician: Date of Last Visit:
Please check Yes or No (If Yes, please fill in details)
Yes No
r r Is the patient in good health?
r r Is the patient taking any medication? Please list:
r r Is the patient allergic to any medication? Please list:
r r Has the patient ever been involved in a serious accident? Explain:
r r Does the patient now or has he/she ever taken Bisphosphonates? (i.e. Fosamax, Zometa, Boniva, Aredia, Actonel, etc)
If yes, which drug?
Female Patients only:
Yes No
r r Has menstruation begun? At what age?
r r Are you pregnant? If yes, what is the due date?
Does the patient have or has he/she had any of the following diseases or conditions? (check Yes or No)
Yes No Yes No Yes No
r r Abnormal bleeding/Hemophilia r r Heart Defect, Murmur, or Disease r r Nervous Disorders
r r Arthritis r r Hepatitis (If yes, circle A B C ) r r Radiation/Chemotherapy
r r Asthma r r Herpes/Fever Blisters r r Rheumatic Fever
r r Bone Disorders r r High or Low Blood Pres r r Tuberculosis
r r Diabetes r r HIV / Aids r r Tumor or Cancer
r r Fainting or Dizziness r r Joint Replacement or Implant r r Tonsils/Adenoids removed
r r Epilepsy r r Latex or Nickel Allergy/Sensitivity
Are there any medical conditions, diseases or problems not discussed that you feel we should be aware of?
Dental History
General Dentist: Date of last visit:
Top of Form
Bottom of Form
What are the main concerns you would most like orthodontics to address?
Patient’s attitude towards orthodontic treatment: r Very Motivated r Will Cooperate (if needed) r Not Motivated
Yes No
r r Is the patient experiencing any dental problems/pain?
r r Have there been any injuries to: (select all that apply) r Face r Mouth r Teeth
r r Has an orthodontist been consulted previously? Reason:______
r r Are you aware that some appointments will be during school/work hours?
Does the patient have or has he/she had any of the following diseases or conditions? (check Yes or No)
Yes No Yes No Yes No
r r Tongue Thrust habit r r Missing Permanent Teeth r r Permanent Tooth extraction
r r Finger/Thumbsucking habit r r Extra Permanent Teeth r r Fear of Dental Work
r r Fingernail biting r r Jaw Pain (TMJ/TMD) r r Clenching/Grinding
r r Mouthbreather r r Jaw Joint clicking/popping r r Previous Orthodontic Therapy
I acknowledge that the above information is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform Dr. Garrett of any changes that occur after this date. I hereby authorize Dr. Garrett and his team to take x-rays and perform a complete orthodontic evaluation/examination. I understand that, where appropriate, credit bureau reports may be obtained.
Signature: Date:
(Patient or Guardian)
Treatment Options:
1)______
Rev. 8/11