Welcome to the office of Drs. Cassinelli and Shanker

Our mission is to treat each individual with care, dignity and compassion, to base all treatment decisions on scientific knowledge, and to be evidence-based and patient-centered in all of our clinical care. Above all, our goal is to obtain excellence in all that we do.

About You Today’s Date______

Name______

Last First MI

MR / MRS / MS / DR

I prefer to be called______○ Male ○ Female

Birthdate______/______/______Age______

SS#______Ethnicity______

Home Address______APT/CONDO #

______

CityStateZip

○Married ○Divorced ○Separated ○Single ○Widowed

Home #______Cell #______Cell Carrier______

Work #______Email______

Employer______

Employer’s Address______

Position______

From whom did you first hear of our office?______

Other family members seen by us?______

General Dentist Name______Physician Name______

Do you have orthodontic Insurance? ○YES ○NO

Spouse information

His/Her Name______

Employer______SS#______

Work #______Cell#______Cell Carrier______

Does your spouse have orthodontic Insurance? ○YES ○NO

Person Responsible for Account

Name______Relationship______

Billing Address______

(if different than home address) APT/CONDO #

______

CITY STATE ZIP

Home #______Cell#______

Employer______Position______

Work #______SS#______

I understand that I am responsible for payment of services rendered.

______

Signature of Responsible Party (In most cases Patient) Date

Emergency Contact

Name______Relationship______

Home #______Work# ______

Cell#______

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes. I authorize the dental staff to perform the necessary dental services that I may need.

______

Signature Date

PLEASE COMPLETE THE DENTAL INSURANCE INFORMATION FORM IF YOU HAVE DENTAL INSURANCE WHICH HAS ORTHODONTIC COVERAGE.

If this office accepts insurance, I hereby authorize and direct payment of the dental/orthodontic benefits directly to this office.

______

Signature of Primary Insurance Owner Date

______

Signature of Secondary Insurance Owner Date

Dental History

The answers to the following questions are for office records only and will be considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation.

Yes No DK/U For the following questions mark Yes, No, or Don't Know/Understand.

______Does patient have difficulty following directions?

______Does patient have difficulty brushing his/her teeth conscientiously?

______Does patient have a strong gag reflex?

______Does patient have learning disabilities or need extra help with instructions?

______Is patient sensitive, self-conscious?

______Supernumerary (extra) or congenitally missing teeth?

______Permanent or "extra” teeth removed?

______Chipped or otherwise injured primary (baby) or permanent teeth?

______Periodontal "Gum problems" or treated for periodontal problems?

______Thumb, finger or sucking habit? Until age ______

______History of speech problems?

______Mouth breathing habit, snoring, difficulty in breathing?

______Any relative with similar tooth or jaw relationships?

______Has patient ever had a prior orthodontic examination or treatment?

If so, when/where? ______

______Would patient object to wearing orthodontic appliances (braces) should they be

recommended?

Date of most recent dental examination ______

How often does patient brush? ______Floss?______

What is the patient, parent or referral sources’ primary concern?

(What brought you here?)

______

______

Realizing that successful treatment greatly depends upon the patient's complete cooperation in following instructions, keeping appointments, and maintaining oral hygiene, are there any restrictions, handicaps, or problems that might be encountered during treatment? If so please list: ______

Medical Alert Summary – Office Use Only

______

1

Forms and Documentations/MedicalDemographic Adult pgs 1-3 of 4

Revised 01/10

Yes No DK/U (if yes please circle)

______Birth defects or hereditary problems?

______Rheumatoid or arthritic conditions?

______Endocrine or thyroid problems?

______Kidney problems?

______Diabetes?

______Cancer or been treated for a tumor?

______Stomach ulcer or hyperacidity?

______Polio, mono, tuberculosis, pneumonia?

______Problems of the immune system?

______AIDS or HIV positive?

______Sexually Transmitted Diseases?

______Hepatitis, jaundice or liver problem?

______Fainting spells, seizures, epilepsy or neurologic problem?

______Mental health or behavioral problem, including ADHD,

bipolar, Depression?

______Vision, hearing, tasting or speech difficulties?

______Loss of weight recently, poor appetite?

______Excessive bleeding, black and blue tendency, anemia or bleeding disorders?

______High or low blood pressure?

______Tires easily?

______Chest pain, shortness of breath or swelling ankles?

______Cardiovascular problem (heart trouble), heart murmur, heart attack, angina, coronary insufficiency, stroke, inborn heart defects or rheumatic heart? If yes please list:

______

______Is premedication required for

cardiovascular problem?

______Do you have a poor or altered diet?

______Frequent headaches, colds

or sore throats?

______Eye, ear, nose or throat condition?

______Hayfever, sinus

trouble, hives?

______Asthma?

Yes No DK/U (if yes please circle)

______Tonsil or adenoid conditions?

______Allergies or drug reactions?

______Known Drug Allergies.

______

______

______Are you taking medication,

nutrient supplements or

non-prescription medicine?

Please list them:

______

______

______Do you or have you taken a

Bisphophonate* drug?

______Does the patient currently

have or ever had a

substance abuse

problem?

______Operations? ______

______Hospitalized for:

______

______

______Other physical problems or symptoms?

______

______

______Being treated by another health care professional? For______

Date of latest physical exam?______

Weight______Height______

Any additional medical information we should be aware of that may impact treatment: ______

I have read and understand the above questions.

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. If there are any changes in my own medical condition/history or dental status I will so inform this practice.

______

Signature of patient Date

*Actonel, Boniva, Fosamax,Fosamax Plus D, Skelid, Didronel, Aredia, Zometa, or Bonefos

Forms and Documentations/Medical Demographic Adult pg 4 of 4

Revised 07/12