Patient Name
    Address
    Town
    Zip Code
    Gender
    MaleFemale
    Home Phone
    Business Phone
    Cell Phone
    Email Address
    Who Referred You?
    Birth Date
    Birthplace
    Marital Status
    MarriedSingleDivorcedSeparatedWidowed
    Dentist's Name
    Date Of Last Checkup
    Physician's Name
    Date Of Last Checkup
    Your Occupation
    Your Social Security
    Spouse's Name
    Spouse's Occupation
    Spouse's Employer Name & Address
    Spouse's Date Of Birth
    Spouse's Social Security
    Spouse's Phone
    Are Any Family Members Currently In Treatment?
    YesNo
    If So, Why?
    Currently Wearing Braces?
    YesNo
    Currently Wearing Retainers?
    YesNo
    Has An Appliance?
    YesNo
    Invisalign?
    YesNo
    Waiting To Begin Treatment?
    YesNo
    1. What Are The Main Concerns That You Would Like Orthodontics To Accomplish?
    2. Are You In Good Health?
    YesNo
    3. Do You Have Regular Medical Examinations?
    YesNo
    4. Have You Ever Had Any Of The Following? (Please Check)
    Allergies To Any Drugs?
    5. Do you require pre-medication for any condition, If so, What?
    6. Is there anything else we should know about your general health? Such as allergies to medications, food, Latex, etc
    7. Have you ever had any injuries to the face, mouth, teeth, or chin? If yes, please explain
    8. Are you a mouth-breather? If yes, please explain
    9. Is there a hereditary background that might contribute to your dental problem
    YesNo
    10. Have you ever had any pain / tenderness in their jaw joint (TMJ)?
    YesNo
    11. Other Remarks
    13. Do you have Insurance?
    14. Name Of Insurance Company?
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