Please enable JavaScript in your browser to complete this form.Name *FirstLastGenderMaleFemaleSocial Security NumberBirthdateHome AddressCityStateZipPrimary Phone NumberPrimary PhoneHomeCellOtherSecondary Phone NumberSecondary PhoneHomeCellOtherEmail AddressEmployer / SchoolMarital StatusSingleMarriedDivorcedWidowedSignificant OtherEmergency Contact NameEmergency Contact RelationshipPhone NumberAddressPrimary Insurance CompanyInsurance Phone NumberGroup NumberPolicy NumberMember ID NumberPolicy Holder's NameRelationship to patientPolicy Holder's Social Security Number (if different from patient)Policy Holder's Birth Date(if different from patient)EmployerWork Phone NumberGeneral Dentist NameLast Dental VisitHow did you hear about our Practice?AdInternetDentistFamily or FriendPhysicianOtherName of person referring(if applicable)Reason for the consultationHave you visited an orthodontist before?YesNoWhen?Reason?Have your tonsils or adenoids been removed?YesNoHave you ever experienced jaw joint pain/discomfort (TMJ/TMD)?YesNoDo you have any missing or extra permanent teeth?YesNoHave you ever had an injury to (select all that apply):TeethMouthChinDo you have speech problems?YesNoIf so, explain:Do your gums bleed?YesNoDo you smoke?YesNoDo you like your smile?YesNoDo you currently or have you ever had any of the following habits?Clenching/Grinding TeethLip Sucking/BitingMouth BreathingNail BitingThumb/Finger SuckingChewing/Eating ProblemsAre you currently being treated by a physician?YesNoReasonPhysicianPhoneDo you have any allergies/sensitivities to medications or latex?YesNoIf yes, please list allergies:Are you currently taking any prescription or over-the-counter medications?YesNoIf yes, please list with dosage:Have you ever taken any Bisphosphonate medications for osteoporosis? (ex: Boniva, Fosomax, Actonel, Reclast)YesNoHave you had any serious illnesses or operations? If yes, describe:Have you ever had a blood transfusion?YesNoIf yes, give approximate dates:Are you pregnant?YesNoNursing?YesNoTaking birth control pills?YesNoCheck if you have or have ever had any of the following:AnemiaArthritis, RheumatismArtificial Heart ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseCancerChemical DependencyChemotherapyCirculatory ProblemsCortisone TreatmentsCough, PersistentCoughing BloodDiabetesTake antibiotics before any dental workEpilepsyFaintingGlaucomaHeadachesHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHIV/AIDSJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSkin RashStrokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcerVenereal DiseaseI 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 of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.Patient Signature and/or Responsible PartyDateDateCommentSubmit