In an effort to provide the best service possible, we ask you to fill this form as completely as possible. Thank you for your cooperation!

1. Patient Information

Section 1 of 10
( ) -
( ) -
( ) -

2. Spouse / Closest Relative

Section 2 of 10
( ) -
( ) -
( ) -

3. Dentist Information

Section 3 of 10

4. General Information

Section 4 of 10

5. Financial Responsibility

Section 5 of 10
( ) -
( ) -
( ) -

6. Dental Insurance

Section 6 of 10
( ) -

( ) -

7. Medical / Dental History

Section 7 of 10

The following information is required to enable us to provide you with the best possible care. All information is strictly private, and is protected by doctor-patient confidentiality. The orthodontist will review the medical history and explain any questions that you do not understand. For the following questions, please mark “YES” “NO,” or “DON’T KNOW/UNDERSTAND (DK/U)


MEDICAL HISTORY QUESTIONS: Now or in the past, have you had:

  Are you being treated for any medical condition at this time or have you been treated for a medical condition within the past two years?
  Has there been a change in your health within the last two years?
  Have you ever had an adverse reaction to any medications, injections or anaesthetics?
  Have you ever had your adenoids and/or tonsils removed?
  Have you ever had hepatitis, jaundice or a liver disorder?
  Do you have a bleeding problem or bleeding disorder?
  Have you ever been diagnosed with asthma?
  Have you ever had a replacement or repair of: a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?
  Do you have a prosthetic or artificial joint?
  Do you have any conditions or therapies that could effect his/her immune system (e.g. leukemia, AIDS, HIV, radiotherapy, chemotherapy)?
  Have you ever been hospitalized for any illness or operation?
  Women: breastfeeding or pregnant?
  Chest pain, angina
  Rheumatic fever
  Heart attack
  Mitral valve prolapse
  Heart murmur
  Shortness of breath
  Pacemaker
  Diabetes
  Tuberculosis
  Stroke
  Autism
  Lung disease
  Steroid therapy
  Cancer
  Stomach ulcers
  Arthritis
  Seizures/Epilepsy
  Kidney disease
  Thyroid disease
  Drug/alcohol dependency
  Nervous disorders
  ADHD

DENTAL HISTORY QUESTIONS: Now or in the past, have you had:

  Been nervous during dental treatment?
  Mouth breather while sleeping or awake (or both)?
  Had habits such as thumb/finger sucking, nail biting, lip sucking, grinding teeth, or an unusual swallow pattern?
  Been informed of any missing or extra permanent teeth
  Had injuries to your face, mouth or teeth?
  Experienced any jaw joint noises, jaw joint pain or limited jaw movement?
  Previously consulted an orthodontist?
  Had any family member had orthodontic treatment?

ALLERGY QUESTIONS: Have you had allergies or reactions to any of the following?

  Medications
  Latex and/or rubber by-products
  Other (e.g. foods, hayfever)

8. Patient Health Information

Section 8 of 10

List any medication, nutritional supplements, herbal medications, and/or non-prescription medicines, including fluoride supplements that you take:

9. Family Medical History

Section 9 of 10

Have the parents or siblings ever had any of the following health problems? If so, please explain:

10. Release & Waiver Signature

Section 10 of 10

I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidences and it is my responsibility to inform this once of any changes in my medical status. I hereby authorize the release of any information related to insurance claims. I consent to the examination by the doctor and I authorize payment of any insurance benefits to the once. I understand that where appropriate, credit bureau reports may be obtained.

I have read the above questions and understand them. 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. I will notify my orthodontist of any changes in my medical or dental health.

Spam Protection

Please Verify That You Are Human!

Choose A Form Submission Option

Select whether you would like to submit the form --OR-- print it out and bring it with you to the office