Dental History for Patients Under 18

Patient

Date*

Name*

First Middle Last

I prefer to be called:

Hobbies or Activities

Birth Date*

Sex*

Male
Female

Social Security Number

School

Grade

Email*

Home Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone*

Cell Phone Carrier, ex. T-mobile

Best form of communication:*

Email
Text
Phone

Parent/Guardian

Custodial Parent Name(s)

Patient Lives with:

Parent #1 Name

First Last

Parent #1 Phone

Parent #1 Occupation

Parent #1 Email

Address (if different than patient address):

Street Address Address Line 2 City State ZIP Code

Parent #2 Name

First Last

Parent #2 Phone

Parent #2 Occupation

Parent #2 Email

Address (if different than patient address):

Street Address Address Line 2 City State ZIP Code

Dentist

Patient’s Dentist

Address

City State

Last Seen

Reason

Next appointment

General Information

What concerns you about your child's teeth?

What concerns your child about his/her teeth?

How does your child feel about orthodontic treatment?

Who suggested that your child may need Orthodontic Treatment?

Why did you select our office/How did you hear about us?

Describe any previous orthodontic treatment or consultations.

Financial Responsibility

Financially Responsible Party #1

First Last

Address (if different than above)

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Email

Social Security Number

Financially Responsible Party #2

First Last

Address (if different than above)

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Email

Social Security Number

Dental Insurance

Do you have dental insurance?

Yes
No

Primary Policy Holder’s Full Name

First Middle Last

Birth Date

Social Security Number

Relationship to patient

Employer

Does this policy have orthodontic benefits?

Yes
No

Insurance company

Group #

Member ID

Patient Health Information

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

Medication & Length Taken

Do he/she take antibiotic pre-medication before dental procedures?

Yes
No

How often does he/she brush?

How often does he/she floss?

Step 1 of 3

Patient

Parent/Guardian

Dentist

General Information

Financial Responsibility

Dental Insurance

Patient Health Information

MEDICAL HISTORY

MEDICAL HISTORY continued

DENTAL HISTORY

Release and Waiver

Patient HIPPA Awareness