1
About You
LAST
FIRST
MI
MR MRS MS DR
Male Female
/ /
STREET ADDRESS
CITY
STATE
ZIP
Single Married Divorced Widowed Seperated
() ()
()
3
Orthodontic Insurance
Primary
Yes No      Yes No
()
/ /
Secondary
Yes No      Yes No
()
/ /
2
Spouse Information
()
/ /
In the event of an emergency, is there someone
who lives near you that we should contact?
() ()
Person Responsible for Account
() ()
4
Medical History
Yes No
()
4
Medical History continued
Good Fair Poor
Yes No
Yes No
Yes No
Yes No     
Yes No
Have you ever had any of the following
diseases or problems?
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following?
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
5
Dental History
Yes No
Yes No
Yes No
Good Fair Poor
Yes No      Yes No
Mouth Teeth Chin
Yes No
While Awake?    While Asleep?
Yes No
Yes No
Yes No
Yes No
Signature
Date
!
Thank you for filling out this form completely.

This reserves the right to verify the credit status of potential patients and / or parents 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

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office.

Signature
Date
OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY
I verbally reviewed the medical / dental information above with the parent / guardian and patient named herein.