Patient Name

Gender
FemaleMale
Birth Date

Age (years & months)

Today's Date

Street Address

City

State

Zip Code

Home Phone #

Work Phone #

Cell Phone #

Email Address

Dentist

Father's Name

D.O.B.

Street Address

City

State

Zip Code

Home #

Work #

Cell #

Mother's Name

D.O.B.

Street Address

City

State

Zip Code

Home #

Work #

Cell #

Name of an individual you would like to contact in an emergency?

Street Address

City

State

Zip Code

Home #

Cell #

Ext #

Subscriber ID #

Dental Insurance Company

Phone

Street Address

City

State

Zip Code

Employer

Phone

Insured Employee Name

D.O.B

Date Employed

Insured Employee SS#

Subscriber ID #

Dental Insurance Company

Phone

Street Address

City

State

Zip Code

Employer

Phone

Insured Employee Name

D.O.B

Date Employed

Insured Employee SS#

Name

D.O.B.

Address

City

State

Zip

Home Phone #

Work Phone #

Ext #

SS #

Driver License #

Employer

Work Address

City

State

Zip

1. Have you been under the care of a medical doctor during the past two years?
YesNo

2. Have you taken any medication or drugs during the past two years?
YesNo
Are you now taking any medication, drugs, or pills?
YesNo

3. Has the patient ever been hospitalized?
YesNo

4. Has the patient had a history of any of the following?

Heart trouble or congenital heart lesions YesNo
Asthma, allergies, or sinus infectionsYesNo
Rheumatic feverYesNo
Bleeding disordersYesNo
Nervousness or hyperactivityYesNo
Hepatitis or liver involvementYesNo
EpilepsyYesNo
Unfavorable reaction to any medicationYesNo
Fainting or dizzinessYesNo
DiabetesYesNo
TuberculosisYesNo
MononucleosisYesNo
Hearing problems or ringing in the earsYesNo
Bone, collagen, or hormonal abnormalitiesYesNo
Grit or grind teeth (day or night)YesNo
Have you seen another orthodontist?YesNo
Injuries to face, mouth or teethYesNo
Missing or extra permanent teethYesNo
Clicking, popping or other problem with jawYesNo
Speech problems, speech or tongue therapyYesNo
Thumb or finger suckingYesNo
Tonsils and adenoids removedYesNo
Mouth breathing problemsYesNo
OtherYesNo

5. Family members treated (Past or Current)

6. Height

Weight

7. Reason for consultation

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from our patients for the costs incurred in their care to remain viable. Financial responsibility on the part of each patient must be determined before treatment.

Patients who carry insurance that covers orthodontic care understand that they are still personally responsible for payments not met by their insurance company. This office will prepare the insurance forms for our patients or assist in making collections from insurance companies and will credit any such collections received to the patient's account. However, this office will not guarantee payment by an insurance company.

A service charge of 1.5% (18% per annum) on the unpaid balance will be assessed on all accounts exceeding ninety days from the due dates unless previously written financial arrangements are made. I understand further that the fee estimates given are valid for 12 months following the initial exam.

In consideration for the professional services rendered to me, or at my request for my minor child or ward, by the orthodontist, I agree to pay the agreed-upon amount for said services, to said orthodontist. Money owed for services will be billed in a timely manner to patients.

I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further item or condition, and I further agree to pay all costs and charges billed, payments made, and interest charges assessed, etc. to the orthodontists' collection agency or collection attorney should collection procedures as described become necessary. I grant my permission to you or your assignee to telephone me at home or at my workplace to discuss matters related to this form.

I authorize the orthodontist or his designees to release financially identifiable information and treatment descriptions and information, either electronically, by facsimile or paper form to my insurance carrier or any related entities that require such information to be submitted. I certify that I have answered all questions on this form accurately and to the best of my knowledge. I hereby agree to abide by the conditions outlined hereon. I agree to pay the remaining balance plus all collection/court costs and fees if a delinquent balance is placed with a collection agency or attorney.

Signature of Patient or Guardian

Date

Relationship to Patient