Patient Information Form (Online)

PATIENT INFORMATION

First Name *

Middle Name

Last Name *

Street Address *

Apartment, suite, etc

City *

Province *

Postal Code *

Country

No. Years at This Address

Phone *

Phone (Work)

Email Address

Birthdate *

Age

Sex *

School

Hobbies/Interests

Has any member of your family undergone orthodontic treatment?YesNo

Name

Do you know anyone being treated in this office?YesNo

Name

Whom may we thank for referring you? *

Reason for seeking treatment: *

If recommended, are you prepared to begin orthodontic treatment today? *YesNo

Please explain why

PARENT/GUARDIAN AND FINANCIALLY RESPONSIBLE PARTIES

First Name *

Last Name *

Marital Status

Address *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone *

Phone (Work)

Relationship to Patient *

Birthdate

Employer

Occupation

Do You Have Orthodontic Insurance? *YesNo

Insurance Company Name

Insured Name

Group #

Policy #

Orthodontic Insurance Coverage: %

Up To $

Add Another Parent/Guardian InfoYesNo

First Name

Last Name

Marital Status

Address

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

Phone (Work)

Relationship to Patient

Birthdate

Employer

Occupation

Do You Have Orthodontic Insurance?YesNo

Insurance Company Name

Insured Name

Group #

Policy #

Orthodontic Insurance Coverage: %

Up To $

EMERGENCY CONTACT

Name of nearest relative not living with you *

Street Address

Apartment, suite, etc

City

Province

Postal Code

Country

Phone *

Phone (Work)

Relationship to Patient

DENTAL HISTORY

Dentist *

Last Cleaning

Last X-Rays

Have you had any injuries to the mouth/jaw area? If yes, please explain *

Any pain or clicking upon mouth opening/closing? If yes, please explain *

Is this your first orthodontic visit? If no, please explain *

Please list any experiences or problems you would like the doctor to be aware of

If the patient is a child, is there any presence of

Thumb SuckingTongue ThrustingMouth Breathing

HEALTH HISTORY

Physician

Date

Current medical condition(s), medication(s)

Have you been hospitalized in the last two years? If yes, please explain

Hepatitis Type

Pregnancy due date

Other health complications not listed aboveIf the patient’s medical status changes, please notify us as soon as possible

Other items you are allergic to

Name of Responsible Party *

Relationship *

Monday	8:00am – 2:00pm
Tuesday	8:00am – 5:00pm
Wednesday	8:00am – 5:00pm
Thursday	8:00am – 5:00pm
Friday	8:00am – 2:00pm**