Online Forms

PATIENT DETAILS

Patient's First Name

Patient's Last Name

Nickname

Patient's Address

City

State

Zip

Gender

Home Phone

Date of birth

Age

Race

Cell Phone

School/Employer

Grade/position

Work phone

How did you hear about our office

Family members treated in our office

Reason for Consultation

Dentist

Date of last cleaning

YesNoHas the patient been examined by an orthodontist before?

GUARDIAN #1 / INSURANCE INFORMATION

Self Spouse Father Mother Stepparent Other (specify)

Guardian's First Name

Guardian's Last Name

Home Phone

Address

City

State

Zip

Employer

Work Phone

Date of birth

Social Security Number

Cell Phone

Guardian's E-Mail

ORTHODONTIC INSURANCE (IF APPLICABLE):

Company Name

Phone

Subscriber/Member ID

GUARDIAN #2 / INSURANCE INFORMATION

YesNo Is there a second guardian and / or additional insurance to add?

Self Spouse Father Mother Stepparent Other (specify)

Guardian's First Name

Guardian's Last Name

Home Phone

Address

City

State

Zip

Employer

Work Phone

Date of birth

Social Security Number

Cell Phone

Guardian's E-Mail

ORTHODONTIC INSURANCE (IF APPLICABLE):

Company Name

Phone

Subscriber/Member ID

SLEEP / AIRWAY ISSUES

YesNoDoes the patient tend to be a mouthbreather?

YesNoDoes the patient snore at night?

YesNoDoes the patient seem rested in the morning?

YesNoIs the patient often sleepy during the day?

YesNoHas the patient seen an Ear, Nose & Throat Specialist?

YesNoIs the patient using a sleep apnea device?

DENTAL/MEDICAL HISTORY

Please check if the patient has a history of the following medical conditions:

YesNoAcid Reflux

YesNoADHD/ADD

YesNoAIDS/HIV

YesNoAnemia

YesNoArthritis

YesNoAsthma

YesNoAutism

YesNoBone Disorders

YesNoCancer

YesNoCerebral Palsy

YesNoChest Pain

YesNoChronic Neck Pain

YesNoClicking of Jaw

YesNoCold Sores/Herpes

YesNoDiabetes

YesNoDown Syndrome

YesNoEndocrine Problems

YesNoEmotional Disorders

YesNoEpilepsy

YesNoHeadaches

YesNoHeart Condition

YesNoHepatitis

YesNoEar Pain

YesNoImmune Problems

YesNoKidney Problems

YesNoLow Blood Pressure

YesNoMuscular Disorders

YesNoNervous Disorders

YesNoOrgan Transplant

YesNoOsteoporosis

YesNoPainful Chewing

YesNoPeriodontal Problems

YesNoProlonged Bleeding

YesNoRheumatic Fever

YesNoScoliosis

YesNoSeizures

YesNoSinus Problems

YesNoTMJ Problems

YesNoTuberculosis

YesNoDo your gums bleed when you brush?

YesNoIs the patient seeing any other dental specialists?

YesNoAny dental restorations needing to be completed?

YesNoHave there ever been any injuries to the face, mouth or chin?

YesNoHave you ever lost or chipped any teeth?

YesNoDo you have any pain or soreness around your face, neck or back?

YesNoIs any part of your mouth sensitive to temperature or pressure?

YesNoIs the patient currently pregnant?

YesNoHave adenoids been removed?

YesNoHave tonsils been removed?

YesNoCurrently taking any medications?

YesNoAre antibiotics necessary prior to treatment?

YesNoAllergies?

YesNoAny diseases or problems not mentioned above?

Please check if the patient has, or ever had, any of the following habits?

YesNoCheek, tongue or lip biting

YesNoClenching Teeth

YesNoFingernail Biting

YesNoGrinding Teeth

YesNoTongue Sucking

YesNoThumb Sucking

YesNoTongue Thrusting

SIGNED CONSENT

I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status.

I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate orthodontic treatment on the above-named patient.

I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.

Typed Name/Signature

Relationship to Patient

Date

If someone other than the parent(s) or guardian(s) listed above will be bringing the patient to appointments, please list here:

By submitting this form you agree to the above mentioned consent statement

Your request has been sent -- we will be in contact with you shortly.

There was an error! Please phone our office.

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Serving
Chicagoland for almost

40 years

ServingChicagoland for almost

40 years

Serving
Chicagoland for almost