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  • Orthodontic InsuranceAbout YouPrimary

    Orthodontic Coverage? Yes No Dental Coverage? Yes NoInsurance Co. Name: _____________________________________________Insurance Co. Address: __________________________________________________________________________________________________________

    City State Zip

    Insurance Co. Phone #: __________________________________________Group # (Plan, Local or Policy #): __________________________________Insured’s Name:__________________ Relation:________________________Insured’s Birthdate: ______________ Insured’s SS #:____________________Insured’s Employer: _______________________________________________Employer’s Address: _____________________________________________________________________________________________________________

    City State Zip

    His / Her Name:__________________________________________________


    Wk #: ______________________ Ext:______ SS #: ____________________

    Birthdate:_________________ DL #:________________________________

    Relative or Friend not living with you.

    His / Her Name:_____________________________ Relation: ____________________

    Wk #: _____ ____ ___________________ Hm #: ______________________________

    SecondaryOrthodontic Coverage? Yes No Dental Coverage? Yes NoInsurance Co. Name: _____________________________________________Insurance Co. Address: __________________________________________________________________________________________________________

    City State Zip

    Insurance Co. Phone #: __________________________________________Group # (Plan, Local or Policy #): __________________________________Insured’s Name:__________________ Relation:________________________Insured’s Birthdate: _____________ Insured’s SS #:_____________________Insured’s Employer: _______________________________________________Employer’s Address: _____________________________________________________________________________________________________________

    City State Zip

    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 Partnered Divorced/Separated Widowed

    Hm #: _____________________ Cell / Other #: _______________________

    Wk #: _____________________ Ext: ______ DL #: _____________________

    Employer: _____________________________________________________

    Employer’s Address:_______________________________________________

    ________________________________________________________________________City State Zip

    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:___________________________________

    Previous Dentist: Present Dentist: _______________________________

    Person Responsible for Account:______________________________

    Payment is due in full at the time of treatmentunless prior arrangements have been approved.

    If this office accepts insurance, I understand that I am responsible for paymentof services rendered and also responsible for paying any co-payment anddeductibles that my insurance does not cover. I hereby authorize payment of thegroup insurance benefits (otherwise payable to me) directly to this office. Iunderstand that I am responsible for all costs of orthodontic treatment. I herebyauthorize release of any information, including the diagnosis and records oftreatment or examination rendered, to my insurance company.

    __________________________________________________________________Signature Date

    Continued on Back

    The benefits of a happy, healthy smile are immeasurable!Our goal is to help you reach and maintain optimal oral health.

    Please fill out this form completely. The better we communicate,the better we can care for you.

    Spouse Information

  • Medical History

    FORM # 980-ORTHO-A V5 GOOD MORNING ORTHO © 2009 1-800-722-4884


    What are the main concerns that you would like orthodonticsto accomplish?


    Have you ever had or been evaluated for orthodontic treatment?

    Yes NoHave you ever had a serious/ difficult problem

    associated with any previous dental work? Yes NoDo you now or have you ever experienced pain /

    discomfort in your jaw joint (TMJ / TMD)? Yes No

    Your current dental health is: Good Fair PoorDo you still have wisdom teeth? 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 NoWhile Awake? While Asleep?

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

    Are you happy with the way your smile looks? Yes NoIf not, what would you change?


    Do you have a personal physician? Yes NoPhysician’s Name:___________________________________________________

    Phone #: _________________________ Date of last visit: _________________

    Your current physical health is: Good Fair PoorAre you currently under the care of a physician? Yes No

    Please explain: _____________________________________________________

    Do you smoke or use tobacco in any other form? Yes No

    Have you had any metal rods, pins or implants? Yes No

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

    Please list each one: _________________________________________________

    Have you ever taken Phen-Fen? (Also known as Redux or Pondimin) Yes No

    If so, when? ________________________________________________________

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

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

    Have you ever had any of the following diseases 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 Erythromycin Y N PenicillinY N Codeine Y N Jewelry/Metals Y N TetracyclineY N Dental Anesthetics Y N Latex Y N Other

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

    I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and that it is myresponsibility to inform this office of any changes in my medical status. I authorize the dental staffto perform any necessary dental services that I may need during diagnosis and treatment, with myinformed consent. This office reserves the right to verify the credit status of potential patients and/orparents of patients prior to extending credit for treatment fees and may, at the discretion of the office,use the services of one or more credit reporting services.

    Signature Date

    I verbally reviewed the medical / dental information with the patient named herein.

    Initials: __________________________ Date: _________________________________

    Doctor’s Comments: _____________________________________________________





    Y N Abnormal Bleeding / HemophiliaY N AIDSY N Alcohol / Drug AbuseY N AnemiaY N ArthritisY N Artificial Bones / Joints / ValvesY N Asthma Y N Blood TransfusionY N Cancer / ChemotherapyY N ColitisY N Congenital Heart DefectY N DiabetesY N Difficulty BreathingY N Emphysema Y N EpilepsyY N Fainting SpellsY N Frequent HeadachesY N GlaucomaY N Hay FeverY N Heart Attack / SurgeryY N Heart MurmurY N Hepatitis

    Y N Herpes / Fever BlistersY N High Blood PressureY N HIVY N Hospitalized for Any ReasonY N Kidney ProblemsY N Liver DiseaseY N Low Blood PressureY N LupusY N Mitral Valve ProlapseY N PacemakerY N Psychiatric ProblemsY N Radiation TreatmentY N Rheumatic / Scarlet FeverY N SeizuresY N ShinglesY N Sickle Cell Disease / TraitsY N Sinus ProblemsY N StrokeY N Thyroid ProblemsY N Tuberculosis (TB)Y N Ulcers Y N Venereal Disease

    ___________________________________________________________Patient Signature Date___________________________________________________________Dentist Signature Date___________________________________________________________Patient Signature Date___________________________________________________________Dentist Signature Date

    Has there been any change in your health status since your last visit? Y NIf Yes, please explain. ________________________________________________________

    Has there been any change in your health status since your last visit? Y NIf Yes, please explain. ________________________________________________________

    Dental History

    MEDICAL HISTORY UPDATEOur office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

    Today’s Date: Name: I prefer to be called: Birthdate: Age: SS: Hm: Cell Other: Employer: 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: Present Dentist: Person Responsible for Account: Insurance Co Name_2: Insurance Co Address_2: Insurance Co Phone_2: Group # Plan, Local or Policy_2: Insured’s Name_2: Insured’s Birthdate_2: Insured’s SS_2: Insured’s Employer_2: Date: Do you have any speech problems: Text10: Dental Coverage: OffPersonal Physician: OffPhysician’s Phone: Physical Health: OffPhysician's Care: OffSmoke: OffImplants: OffDrugs: OffList any prescription or over-the-counter drugs: Phen-fen: OffWhen have you taken Phen-Fen?: Have you ever taken Fosamax, or any other bisphosphonate: OffBirth control: OffAre you pregnant: OffWeek of pregnancy: Nursing: OffHemophilia: OffAIDS: OffAlcohol Abuse: OffAnemia: OffArthritis: OffArtificial Joints: OffAsthma: OffBlood Transfusion: OffCancer: OffColitis: OffHeart Defect: OffDiabetes: OffBreathing: OffEmphysema: OffEpilepsy: OffFainting Spells: OffHeadaches: OffGlaucoma: OffHay Fever: OffHeart Attack: OffHeart Murmur: OffHepatitis: OffHerpes: OffHigh Blood Pressure: OffHIV: OffHospitalization: OffKidney: OffLiver Disease: OffLow Blood Pressure: OffLupus: OffMitral Valve Prolapse: OffPacemaker: OffPyschiatric Problems: OffRadiation: OffScarlet Fever: OffSeizures: OffShingles: OffSickle Cell: OffSinus Problems: OffStroke: OffThyroid Problems: OffTB: OffUlcers: OffVeneral Disease: OffPlease list any serious medical conditions that you have ever had 1: Aspirin: OffCodeine: OffDental Anesthetics: OffErythromycin: OffJewelry: OffLatex: OffPenicillin: OffSulfur: OffTetracycline: OffPlease list any other drugsmaterials that you are allergic to: Why have you come to the dentist today: Problem with dental work: OffDental Health: OffWisdom Teeth: OffE-mail Address: Gender: OffMarital Status: OffHome Address: City: State: Zip: Wk: Ext: DL: Employer’s Address: Employer’s City: Employer’s State: Employer’s Zip: Dentist: OffSpouse Name: Spouse Employer: Spouse Wk: Spouse Ext: Spouse SS: Spouse DL: Spouse Birthdate: Relative Name: Relation: Relative Hm: Relative Wk: Orthodontic Coverage: OffInsurance Co Name_1: Insurance Co Address_1: Insurance Co City_1: Insurance Co State_1: Insurance Co Zip_1: Insurance Co Phone_1: Group # Plan, Local or Policy_1: Insured’s Name_1: Insured’s Relation_1: Insured’s Birthdate_1: Insured’s SS_1: Insured’s Employer_1: Insured’s Employer’s Address_1: Insured’s Employer’s City_1: Insured’s Employer’s State_1: Insured’s Employer’s Zip_1: Orthodontic Coverage_2: OffDental Coverage_2: OffInsurance Co City_2: Insurance Co State_2: Insurance Co Zip_2: Insured’s Relation_2: Insured’s Employer Address_2: Insured’s Employer City_2: Insured’s Employer State_2: Insured’s Employer Zip_2: Personal physician's name: Last visit to physician: Explain your care: Evaluated for Orthodontic treatment: OffTMJ: OffInjury: OffDo you breathe through your mouth: OffWhile Awake: OffWhile Asleep: OffExtra Teeth: OffYour smile: OffWhat would you change about your smile:

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