TO THE ORTHODONTISTHave you ever had or been evaluated for orthodontic treatment?Yes No Have you ever had a serious / difficult problem associated with any previous dental work? Yes

TTO O THE ORTHE ORTHODONTISTTHODONTIST

Today’s Date:

E-Mail Address:

Name:LAST FIRST MI MR MRS MS DR

I prefer to be called: Male Female

Birthdate: Age: SS #:

Home Address: APT/CONDO #:

CITY STATE ZIP

Single Married Divorced Widowed Separated

Hm #: Pager / Other #:

Wk #: Ext: DL #:

Employer:

Employer’s Address:

How long there? Occupation:

Where & when are best times to reach you?

Whom may we Thank for referring you?

Other family members seen by us:

General Dentist:

Last Visit Date:

His / Her Name:

Employer:

Wk #: Ext: SS #:

Birthdate:

Primary

Orthodontic Coverage: Yes No Dental Coverage: Yes No

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #:

Group # (Plan, Local or Policy #):

Insured’s Name: Relation:

Insured’s Birthdate: Insured’s ID #:

Insured’s Employer:

Secondary

Orthodontic Coverage: Yes No Dental Coverage: Yes No

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #:

Group # (Plan, Local or Policy #):

Insured’s Name: Relation:

Insured’s Birthdate: Insured’s ID #:

Insured’s Employer:

In the event of an emergency, is there someone

who lives near you that we should contact?

His / Her Name: Relation:

Wk #: Hm #:

SPOUSE INFORMATION

Person Responsible for Account:

Wk #: Ext: Hm #:

Billing Address:

Relation: SS #:

Employer: DL #:

ORTHODONTIC INSURANCE

MEDICAL HISTORY

Do you have a personal physician? Yes No

Physician’s Name: ______________________________________________________

Phone #: ___________________________ Date of last visit: __________________

ABOUT YOU

Please fill out this form completely.The better we communicate, the

better we can care for you.

The benefits of a happy, healthysmile are immeasurable! A beautifulsmile is a wonderful asset.

CONTINUED ON BACK

Have you ever had any of the followingdiseases or medical problems?

Please list any serious medical condition(s) that you have ever had:

Are you allergic to any of the following?

Y N Aspirin Y N Dental Anesthetics Y NPenicillinY N Any Metals/Plastics Y N Erythromycin Y NTetracyclineY N Codeine Y N Latex Y NOther

Please list any other drugs/materials that you are allergic to:

What are the main concerns that you would like orthodontics to accomplish?

Have you ever had or been evaluated for orthodontic treatment? Yes No

Have you ever had a serious / difficult problem associatedwith any previous dental work? Yes No

Do you now or have you ever experienced pain /discomfort in your jaw joint (TMJ / TMD)? Yes No

Your current dental health is: Good Fair Poor

Do you like your smile? Yes No Gums ever bleed? Yes No

Have you ever had an injury to your: Mouth Teeth Chin

Do you have any speech problems?

Do you generally breathe through your mouth? Yes NoIf yes, please check: While Awake? While Asleep?

Do you have any missing or extra permanent teeth? Yes No

Have you ever taken Fosamax, or any other bisphosphonate? Yes No

Have you ever taken Phen-Fen? Yes NoDo you smoke or use tobacco in any form? Yes No

understand that the information that I havegiven today is correct to the best of my

knowledge. I also understand that this informationwill be held in the strictest confidence and it is myresponsibility to inform this office of any changes in mymedical status. I authorize the dental staff to perform anynecessary dental services that I may need during diagnosisand treatment with my informed consent.

Signature Date

This office reserves the right to verify the credit status of potential patientsand / or parents of patients prior to extending credit for treatment fees and may, atthe discretion of the office, use the services of one or more credit reporting services.

Signature Date

If this office accepts insurance, I understand that I am responsible for payment of services ren-dered and also responsible for paying any co-payment and deductibles that my insurance doesnot cover. I hereby authorize payment of the group insurance benefits (otherwise payable tome) directly to this office.

Signature Date

Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

Thank you for filling out this form completely.

I verbally reviewed the medical / dental information above with the patient named herein. Initials: Date:

Doctor’s Comments:

MEDICAL HISTORY continued

FORM #ORTHO-2A CLASSIC ORTHO www.informsonline.com © 2009 1-800-722-4884

Y N Abnormal BleedingY N AnemiaY N Artificial Bones / Joints / ValvesY N Asthma /Arthritis Y N Blood TransfusionY N Cancer / ChemotherapyY N Congenital Heart DefectY N DiabetesY N Difficulty BreathingY N Drug / Alcohol AbuseY N EmphysemaY N Epilepsy / Seizures / FaintingY N Fever Blisters / HerpesY N GlaucomaY N Heart Attack / StrokeY N Heart MurmurY N Heart Surgery / Pacemaker

Y N HemophiliaY N HepatitisY N High / Low Blood PressureY N HIV+ / AIDSY N Hospitalized for Any ReasonY N Kidney ProblemsY N Mitral Valve ProlapseY N Psychiatric ProblemsY N Radiation TreatmentY N Rheumatic / Scarlet FeverY N Severe / Frequent HeadachesY N ShinglesY N Sickle Cell Disease / TraitsY N Sinus ProblemsY N Tuberculosis (TB)Y N Ulcers / ColitisY N Venereal Disease

Your current physical health is: Good Fair Poor

Are you currently under the care of a physician? Yes No

Please explain:

Are you taking any prescription / over-the-counter drugs? Yes No

Please list each one:

For Women: Are you using a prescribed method of birth control? Yes NoAre you pregnant? Yes No Week #:

Are you nursing? Yes No

OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY

DENTAL HISTORY

I prefer to be called: Age: SS: Home Address: STATE: ZIP: Pager Other: Employer: Employer’s Address: Where & when are best times to reach you: General Dentist: Last Visit Date: Person Responsible for Account: Physician’s Name: Date of last visit: Insured’s Name_2: Insured’s Employer_2: Insured’s Birthdate_2: Insurance Co Address_2: Insurance Co Name_2: Email Address: Name: Birthdate: City: Home #: Work #: Ext1: DL1: How long there?: Occupation: Whom may we thank: Other family members seen by us: Spouse Name: Spouse Employer_2: Spouse Wk: SPOUSE ext: SPOUSE SS: Soouse Birthdate: Responsible Person Wk_2: Responsible Person Hm: Responsible Person EXT: Responsible Person Billing Address: Responsible Person Relation: Responsible Person Employer_3: Responsible Person SS: Responsible Person DL: Physician Ph: Emergency Wk_3: Emergency Hm: Emergency relation: Emergency Name_2: Insured’s Relation_2: 2Group # Plan, Local or Policy: 2Insurance Co Phone: Insured’s Employer_1: 2Insured’s ID: 1Insured’s ID: Insured’s Birthdate_1: Insured’s Name_1: 1Group # Plan, Local or Policy: 1Insurance Co Phone: 1Insurance Co Address_2: 1Insurance Co Name_2: Check Box5: OffCheck Box6: OffCheck Box7: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffCheck Box11: OffCheck Box12: OffCheck Box13: OffCheck Box14: OffCheck Box15: OffCheck Box16: OffCheck Box17: OffCheck Box18: OffCheck Box19: OffCheck Box20: OffCheck Box21: OffInsured’s Relation_1: Health_good: OffHealth_fair: OffHealth_poor: OffPhysician_yes: OffPhysician_no: OffPlease explain: Drugs_yes: OffDrugs_no: OffAre you taking any prescription over-the-counter drugs: Pills_yes: OffPills_no: OffPregnant_yes: OffPregnant_no: OffWeek#: Nursing_no: OffNursing_yes: OffBleeding Y: OffBleeding N: OffAnemia Y: OffAnemia N: OffBones Y: OffBones N: OffAsthma Y: OffAsthma N: OffTransfusion Y: OffTransfusion N: OffCancer Y: OffCancer N: OffCongenital Heart Defect Y: OffCongenital Heart Deffect N: OffDiabetes Y: OffDiabetes N: OffDifficulty Breathing Y: OffDifficulty Breathing N: OffDrug Abuse Y: OffDrug Abuse N: OffEmphysema Y: OffEmphysema N: OffEpilepsy Y: OffEpilepsy N: OffFever Blisters Y: OffFever Blisters N: OffGlaucoma Y: OffGlaucoma N: OffHeart Attack Y: OffHeart Attack N: OffHeart Murmur Y: OffHeart Murmur N: OffHeart Surgery Y: OffHeart Surgery N: OffHemophilia Y: OffHemophilia N: OffHepatitis Y: OffHepatitis N: OffBlood Pressure Y: OffBlood Pressure N: OffHIV Y: OffHIV N: OffHospitalization Y: OffHospitalization N: OffKidney Y: OffKidney N: OffMVP Y: OffMVP N: OffPhychiatric Y: OffPhychiatric N: OffRadiation Y: OffRadiation N: OffRheumatic Fever Y: OffRheumatic Fever N: OffHeadaches Y: OffHeadaches N: OffShingles Y: OffShingles N: OffSickle Cell Y: OffSickle Cell N: OffSinus Y: OffSinus N: OffTB Y: OffTB N: OffUlcer Y: OffUlcers N: OffVenereal Disease Y: OffVenereal Disease N: OffAny serious medical conditions: Aspirin Y: OffMetals Y: OffMetals N: OffCodeine Y: OffAnesthetics Y: OffAnesthetics N: OffErythromycin Y: OffErythromycin N: OffLatex Y: OffPenicillin Y: OffPenicillin N: OffTetracycline Y: OffTetracycline N: OffOther Y: OffOther N: OffAllergic: Codeine N: OffAspirin N: OffLatex N: OffWhat do you want: Evaluated_yes: OffEvaluated_no: OffPrevious problems_yes: OffPrevious problems_no: OffTMJ_yes: OffTMJ_no: OffDental Health_good: OffDental Health_fair: OffDental Health_Poor: OffSmile_yes: OffSmile_no: OffGums bleed_yes: OffGums bleed_no: OffMouth: OffTeeth: OffChin: OffAny speech problems: Mouth breather_yes: OffMouth breather_no: OffWhile Awake: OffWhile Asleep: OffTeeth_yes: OffTeeth_no: OffTobacco_yes: OffTobacco_no: OffPhen-Fen_yes: OffPhen-Fen_no: OffFosamax_yes: OffFosamax_no: OffToday’s Date: