ORTHODONTIC CONSULTATION FORM
(PLEASE PRINT)
DATE ______
PATIENT’S NAME ______SURNAME GIVEN NAME INITIAL PREFERED
ADDRESS ______
NOSTREETCITY OR TOWNPOSTAL CODE
HOME #. ______CELL #. ______EMAIL: ______
DATE OF BIRTH ______PRESENT AGE _____
M/D/Y
SCHOOL ______GRADE ______GENDER ______
SPORTS ______MUSICAL INSTRUMENT ______
WHO REFERRED YOU TO THIS OFFICE? ______
HAS ANYONE ELSE IN THE FAMILY HAD OR HAVING ORTHODONTIC THERAPY? □ YES □ NO
IF YES, WHO? ______WHEN? ______AND BY WHOM? ______
HOW HAPPY ARE YOU (AND PARENTS) ABOUT THE TREATMENT RESULTS? ______
______
DENTAL HISTORY
(PLEASE EXPLAIN ALL “YES” ANSWERS)
DENTIST’S NAME ______
ADDRESS ______
HOW LONG HAVE YOU BEEN GOING TO THE ABOVE DENTIST? ______
HOW OFTEN DO YOU GO TO YOUR DENTIST? ______
WHEN WAS YOUR LAST DENTAL APPOINTMENT? ______
HAS THE PATIENT HAD A PREVIOUS ORTHODONTIC EXAMINATION? ______
CURRENTLY PAST
INJURY TO THE FACE, MOUTH OR TEETH? □NO □ YES ______□NO □YES ______
FINGER, THUMB OR TONGUE SUCKING? □NO □YES ______□NO □YES ______
MOUTH BREATHING WHILE AWAKE? □NO □YES ______□NO □YES ______
GRINDING OR CLENCHING OF TEETH? □NO □ YES ______□NO □YES ______
DIFFICULTY IN CHEWING? □ NO □ YES ______□NO □YES ______
SPEECH PROBLEMS? □ NO □ YES ______□NO □YES ______
CLICKING OR DISCOMFORT IN THE JAW? □ NO □ YES ______□NO □YES ______
OTHER ADDITIONAL INFORMATION? ______
MEDICAL HISTORY
(PLEASE EXPLAIN ALL “YES” ANSWERS)
PHYSICIAN’S NAME ______
ADDRESS ______PHONE ______
CURRENTLY TAKING MEDICATION? □NO □YES ______
CURRENTLY UNDER PSYCHOLOGICAL GUIDANCE?□NO □YES ______
HAS THE PATIENT HAD THE FOLLOWING ILLNESSESS?
JAUNDICE □NO □YES ______
HEPATITIS □NO □YES ______
RHEUMATIC FEVER □NO □YES ______
OTHER SEVERE ILLNESSES □ NO □YES ______
REMOVAL OF TONSILS AND/OR ADENOIDS □NO □YES ______
OVER →
Medical History con’t
RECENT OR PERTINENT SURGERY□NO □YES ______
DOES THE PATIENT HAVE THE FOLLOWING CONDITIONS?
AIDS OR CARRIER OF AIDS VIRUS□NO □YES ______
ASTHMA□NO □YES ______
ALLERGIES - INCLUDING LATEX OR NICKEL□NO □YES ______
BIRTH DEFECTS□NO □YES ______
BLOOD DISORDERS□NO □YES ______
EPILEPSY□NO □YES ______
DIABETES□NO □YES ______
ARTHRITIS□NO □YES ______
HEART AND/OR LUNG CONDITIONS□NO □YES ______
FREQUENT □ COLDS □ SORE THROATS□NO □YES ______
PREGNANT OR THE POSSIBLITY□NO □YES ______
OTHER MEDICAL CONDITIONS NOT LISTED□NO □YES ______
RESPONSIBLE PARTY INFORMATION
MOTHERS NAME______
ARE YOU THE LEGAL GUARDIAN □ NO □ YES Birth Date:______
ADDRESS IF DIFFERENT THAN PATIENT
______
NO.STREETCITY/TOWNPOSTAL CODE
PHONE #’S RES:______BUS:______CELL:______
EMAIL ADDRESS:______
NAME OF EMPLOYER______
FATHERS NAME______
ARE YOU THE LEGAL GUARDIAN □ NO □ YES Birth Date:______
ADDRESS IF DIFFERENT THAN PATIENT
______
NO.STREETCITY/TOWNPOSTAL CODE
PHONE #’S RES:______BUS:______CELL:______
EMAIL ADDRESS:______
NAME OF EMPLOYER______
DO YOU HAVE A DENTAL PLAN COVERING ORTHODONTIC TREATMENT □ NO□ YES
NAME OF INSURANCE COMPANY ______
NAME OF POLICY HOLDER ______
PARENTS/GUARDIAN’S SIGNATURE: ______
PLEASE NOTE: IT IS IMPORTANT THAT YOU COMPLETE AND BRING THIS FORM TO YOUR APPOINTMENT OR YOU CAN FAX IT TO (709)-489-1435 OR EMAIL:
IT IS THE POLICY OF THIS OFFICE TO BILL AND RECEIVE FULL PAYMENT FROM OUR PATIENTS. WE REQUIRE THAT YOU MAKE PAYMENTS FROM YOUR INSURANCE COMPANY PAYABLE TO YOU. WE HAVE STANDARD FORMS IN OUR OFFICE FOR YOUR USE.