Orthodontic Consultation Form

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.