In an effort to provide the best service possible, we ask you to fill this form as completely as possible. Thank you for your cooperation!

1. Patient Information

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2. Parent / Guardian Information

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3. Dentist Information

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4. General Information

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5. Financial Responsibility

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6. Dental Insurance

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7. Medical / Dental History

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The following information is required to enable us to provide you with the best possible care. All information is strictly private, and is protected by doctor-patient confidentiality. The orthodontist will review the medical history and explain any questions that you do not understand. For the following questions, please mark “YES” “NO,” or “DON’T KNOW/UNDERSTAND (DK/U)

MEDICAL HISTORY QUESTIONS: Now or in the past, have you had:

  Is your child being treated for any medical condition at this time or has your child been treated for a medical condition within the past two years?
  Has your child ever had an adverse reaction to any medications, injections or anesthetics?
  Has your child ever had his/her adenoids and/or tonsils removed?
  Has your child ever had hepatitis, jaundice or a liver disorder?
  Does your child have a bleeding problem or bleeding disorder?
  Has your child ever been diagnosed with asthma?
  Has your child ever had a replacement or repair of: a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?
  Does your child have a prosthetic or artificial joint?
  Does your child have any conditions or therapies that could effect his/her immune system (e.g. leukemia, AIDS, HIV, radiotherapy, chemotherapy)?
  Has your child ever been hospitalized for any illness or operation?
  Rheumatic fever

DENTAL HISTORY QUESTIONS: Now or in the past, have you had:

  Been nervous during dental treatment?
  Mouth breather while sleeping or awake (or both)?
  Had habits such as thumb/finger sucking, nail biting, lip sucking, grinding teeth, or an unusual swallow pattern?
  Been informed of any missing or extra permanent teeth
  Had injuries to your face, mouth or teeth?
  Experienced any jaw joint noises, jaw joint pain or limited jaw movement?
  Previously consulted an orthodontist?
  Had any family member had orthodontic treatment?

ALLERGY QUESTIONS: Have you had allergies or reactions to any of the following?

  Latex and/or rubber by-products
  Other (e.g. foods, hayfever)

8. Patient Health Information

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List any medication, nutritional supplements, herbal medications, and/or non-prescription medicines, including fluoride supplements that your child takes:

9. Family Medical History

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Have the parents or siblings ever had any of the following health problems? If so, please explain:

10. Release & Waiver Signature

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I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidences and it is my responsibility to inform this once of any changes in my medical status. I hereby authorize the release of any information related to insurance claims. I consent to the examination by the doctor and I authorize payment of any insurance benefits to the once. I understand that where appropriate, credit bureau reports may be obtained.

I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.

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