Is the patient under 18?*YesNoPatient InformationPatient's Name*Prefers To Be CalledMailing Address* Mailing Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Phone*Date Of Birth* Date Format: MM slash DD slash YYYY SexMaleFemaleSSN*SchoolGradeEmail Whom may we thank for referring you to our office?Name and age of other siblings?Responsible Party InformationName*Marital StatusSingleMarriedDivorcedWidowedRelationship to PatientSSN*Date Of Birth* Date Format: MM slash DD slash YYYY Email* Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code How long at this address?Do you own or rent?OwnRentHave you been at this address for more than 3 years?*YesNoPrevious Address Previous Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Phone*Work PhoneCell/PagerEmployerOccupationNumber Of Years EmployedSpouse's NameRelationship to PatientSSNDate Of Birth Date Format: MM slash DD slash YYYY Email Work PhoneCell/PagerEmployerOccupationNumber Of Years EmployedDental Insurance InformationDo you have dental insurance?*YesNoInsured's Full Name*SSN*Date Of Birth* Date Format: MM slash DD slash YYYY Insurance Company*Group NumberContract/ID NumberInsurance Complete Address* Insurance Complete Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Insurance Phone*Insured's EmployerEmployer's Complete Address Employer's Complete Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Employer's PhoneDo you have dual coverage?*YesNoInsured's Full Name*SSN*Date Of Birth* Date Format: MM slash DD slash YYYY Insurance Company*Group NumberContract/ID NumberInsurance Complete Address* Insurance Complete Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Insurance Phone*Insured's EmployerEmployer's Complete Address Employer's Complete Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Employer's PhoneEmergency Contact InformationEmergency Contact*Emergency Contact Address Emergency Contact Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Emergency Contact Phone*Medical and Dental Health InformationPatient's DentistDate Of Last Dental Visit Date Format: MM slash DD slash YYYY Do you need a referral to a dentist?YesNoWhat concerns you the most about your teeth?Has an orthodontist previously been consulted?YesNoAre antibiotics necessary for teeth cleaning?YesNoIs there any dental work that needs to be completed prior to orthodontic treatment?YesNoPatient's PhysicianDate Of Last Physical Exam Date Format: MM slash DD slash YYYY Is the patient under the care of a physician at this time? If yes, please explain.List any medications being taken at this time.List all allergies.Has the patient ever had any of the following medical or dental problems? Abnormal Bleeding Bone Disorders Cancer or Tumor Diabetes Hepatitis Sinus Problem Latex Allergy Plastic/Metal Allergy Tooth/Jaw Trauma Clenching/Grinding Jaw Clicking/Popping Painful Joints Dental Pain Fainting or Dizziness Cold Sores/Herpes Nervous Disorders Epilepsy/Convulsions/Seizures Aids/HIV Positive Hemophilia/Prolonged Bleeding Tuberculosis/Positive PPD Asthma or Hayfever Anemia Finger/Thumb Sucking Lip/Tongue Biting Tonsils/Adenoid Problems Arthritis/Osteoporosis Alcoholism/Drug Addiction Frequent Colds/Sore Throat Sexually Transmitted Disease Bisphosphonates Thyroid Problems Kidney Disease Liver Disease High Blood Pressure Bruise/Bleed Easily Pregnant Now Heart Murmur or MVP Disabilities Mouth Breathing Tongue Thrust Speech Problems Smoke/Chew Tobacco Ear Infections Headaches Cavities Now Extra Teeth Missing Permanent Teeth Please explain any medical or dental problems that you have had:AffirmationAffirmation* I affirm that the information that I have giiven is correct to the best of my knowledge. It will be held in the strictest of confiidence and it iis my responsiibility to inform this office immediately of any changes in medical status. I understand that where appropriate, credit reports may be obtained.*Patient/Parent/Legal Guardian*Date Submitted* Date Format: MM slash DD slash YYYY