Orthodontic Health Form | Patient Health History Form

Comments

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Patient Biographical Information

First Name*

Middle Initial

Last Name*

Nickname

Birthdate*

Gender*

Address*

Street Address City State ZIP

Main Phone*

2nd/Cell Phone

Email

Social Security #

Please list the names of any friends or family currently in the practice

List any sports, hobbies, or musical instruments played

Whom may we thank for referring you to our practice?

Financial Party Information

First Name*

Middle Initial

Last Name*

Birthdate*

Relationship to Patient

Email

Address*

Street Address City State ZIP

Main Phone*

2nd/Cell Phone

Social Security #

Do you have insurance that covers orthodontics?

Yes

No

If so, please name the Insurance Company

Employer

Occupation

Length of Employment

Work Phone

Patients Under 18

If patient is under the age of 18, please answer the following questions:

Please list the name and birthdate of any siblings

Height

Weight

School

Grade

Father/Guardian 1 Name

Mother/Guardian 2 Name

Has patient begun puberty

No

Yes

If patient is a girl, has menstruation begun

No

Yes

If patient is a boy, has their voice changed or have facial hair

No

Yes

Has the patient grown in the past year or has their shoe size changed recently

No

Yes

Patient's interest in treatment

Has either biological parent ever had orthodontic treatment

Patient Health History Form

Begin Your Journey to a Confident Smile

Patient Biographical Information

Financial Party Information

Dental History

Section Break

Medical History

Patients Under 18