Welcome to Our Club of Smiles

WelcometoOurClub of Smiles!

Whois Completing thisForm?

Name Date

Signature

Whowill Webe Seeing?

Patient Name

FirstLastMI

ButI would rather be called....Gender (circle one)MF

Address City State Zip Code Phone ( ) Birthdate Age School orWorkplace Hobbies or Interests

Whowill be Responsible forTreatmentDecisions?

Financial information will be requested at a later date.

Name

FirstLastMI

Address

CityState Zip Code

Phone ()

Alternate Phone ()

Relationship to Patient

Pleaselist an additional person who can be responsible for the patient’s treatment decisions.

Their Name Their phone ()

Your Dentist From a friend or relative

Howdid Youfind Us?

(PleaseCheckOne)

Advertisement

Internet

Whom may we thank?

FamilyMember is/was a patient Phonebook

Office Sign

Other

If other:

Patient Name Date

Initial (person completing this form)

WeNeed toKnowjust aLittle Bit More....

HowareYouFeeling?

Is the patient in good health?Yes No Details

Doesthe patient have a history

of significant illness of disease?Yes No Details

Isthe patient allergic to any

drugs or medications?Yes No Details

Doesthe patient have any

environmental allergies?Yes No Details

Doesthe patient have any history

of heart problems?Yes No Details

Doesthe patient have any history

of rheumatic fever or heart murmur?Yes No Details

Doesthe patient have any history

of bleeding disorders?Yes No Details

Doesthe patient take premedication

for dental cleanings?Yes No Details

Isthere any condition that may

affect the patients orthodontic care? Yes No Details

Isthe patient taking any

medications currently?Yes No Details

Whois YourDentist?

DentistName For how many years? DentistAddress Date of last dental check-up

Has the patient ever had any injury to the face, mouth, or teeth?Yes No

If yes, please explan

Does the patient have any known dental problems?Yes No

If yes, please explan

Reasonfor seeking an orthodontic evaluation Has another orthodontist been consulted?Yes No

If yes, whom?

Patient Name Date

Initial (person completing this form)

Do youhave

InsuranceCoverage?

*Please fillout all information below as completely and accurately as possible in orderto obtain correct verfication and payment from yourinsurance in a timely manner.

Whois thePrimaryInsuranceUnder?

Member Name

FirstLastMI

Member’s Birthdate

Member’s S.S. Number Member’s ID # Relationship to Patient Patient’s Birthdate Insurance Company Name

Note: If Delta Dental, please specify which location. (Ex: Delta Dentalof PA)

Insurance Company Phone () Group Number (on card)

WhereDo theyWork?

Employer EmployerAddress City State Zip Code Employer Phone ( )

Do youhaveadditional InsuranceCoverage?

Whois theSecondary InsuranceUnder?

Member Name

FirstLastMI

Member’s Birthdate

Member’s S.S. Number Member’s ID # Relationship to Patient Patient’s Birthdate Insuance Company Name

Note: If Delta Dental, please specify which location. (Ex: Delta Dentalof PA)

Insurance Company Phone () Group Number (on card)

WhereDo theyWork?

Employer EmployerAddress City State Zip Code Employer Phone ( )