PATIENT INFORMATION
Full Name:
*
Age:
Date of Birth:
Male or Female:
Male
Female
Social Security:
Email
*
Phone
*
Work Number:
Other/Cell Number:
Text Reminder:
Yes
No
Address
*
City
*
State
*
Postal code
*
EMERGENCY CONTACT
Contact Name:
Relationship to the Patient:
Contact Phone:
Contact Email:
RESPONSIBLE PARTY
Name:
Age:
Date of Birth:
Relationship to Patient:
Social Security:
Email:
Phone:
Work Phone:
Other/Cell Number:
Text Reminder:
Yes
No
Home Address:
Apartment Number:
City:
ZIP / Postal Code:
Employer/Company:
HOW WERE YOU INTRODUCED
TO OUR PRACTICE?
Dentist
Friend/Family
Social Media
Google/Internet Search
Drive By
Other
PRIMARY DENTAL INSURANCE
Name:
Date of Birth:
Social Security:
Relationship to Patient:
Insurance Company’s Name:
Address:
Phone:
Group/Policy:
Is there orthodontic coverage?
Yes
No
GENERAL DENTIST INFORMATION
Dentist:
Street Address:
Phone Number:
Last Visit:
Reasons for your orthodontic visit:
Consultation
Braces
Clear Aligner Therapy
Dentofacial Orthopedics
Do you have other family members who are also our patients?
Yes
No
MEDICAL HISTORY
Today's Date: