Patient's Last Name First Name Middle
Patient's E-Mail Address :
Preferred to be called Sex
Home Address
City State Zip
Home Phone Age Birth date
Phone Number to Reach Someone During the Day
Patient's dentist's Referred By
Do you know a patient currently in our practice ?  If so, whom ?
Who noticed orthodontic problem?
Patient Dentist Other

Describe the orthodontic problem in your own words.

What concerns you most about the thought of orthodontic treatment? Appearance in appliances
Cost
Length of time
Discomfort
Results
Other
Employer's Name  
Business Address  
City, State, Zip  ,  
,
Business Phone  
Occupation  

Maritial
Status

Single
Married
Divorced
Separated
Widowed

Spouse    

Name  
Employer's Name  
Business Address  
City State, Zip  
,
Business Phone  
Occupation  
Person Responsible for Account
SS#

Other Responsible Person     

Name  
Address  
City, State, Zip  ,  
,
Phone  
Occupation  
 

Names and Ages of Children

Medical History     

Physician's Name  
Address  
City, State, Zip  ,  
,
Phone  
  NO YES
Have you experienced any health problems?
     Explain :
Any major change in your  health recently?
     Explain :
Are you currently under a physicians care?
Explain :
Are you currently taking medications?
     Explain :
Are you allergic to any medications?
     Explain :
Have you received a blood transfusion?
     Explain :
Have your tonsils or adenoids been removed?
     Explain :
Have you been in a risk group for AIDS?
     Explain :
Do you require antibiotics before dental TX?
Explain :
Please check if your child has had any of the following conditions:
  NO YES
Heart Murmur
Heart Surgery
Developmental Disorder
Asthma
Hepatitis
Diabetes
Tuberculosis
Growth Disorders
Emotional Problems
Frequent Headaches
Bone Disorders
Mouth Breather
Is there any condition or problem
that you think we should know about?
Comments:
Dental History
Frequency of Dental Checkups Twice a year
Once a year
Only if a problem exists
  NO YES
Is there any unfinished care to be
completed with your dentist?
     Explain:
Have you consulted an orthodontist previously?
     With whom?
Has you had any previous orthodontic treatment?
     With whom?
Pleased Check if there is a history of:
Clenching Teeth
Grinding Teeth
Speech Problems
     What Sounds :
Muscular Soreness around the head and neck
Headaches (More than normal)
Jaw joint soreness
Jaw joint clicking
Jaw joint popping
Ringing in the ears
Insurance Information
Do you have orthodontic insurance :   YES         NO
     A dental insurance policy is a contract between the insured and the insurance company.  Our professional services are rendered and charged directly to the patients account and the patient or person responsible for the account is responsible for payment of all fees incurred.  For your convenience, we will gladly assist you in submitting insurance claim forms from your insurance carrier pertaining to any charge for care in our office.  If you wish assistance, we ask that you provide us with claim forms to your insurance carrier on your first visit.  Otherwise we will assume you are submitting all claims to your insurance carrier.  We will accept assignment of benefits from your insurance company if possible.
Name of insured : (employee)
SS#
Date of Birth
Name of insurance Company
Group #
 
Name of insured : (employee)
SS#
Date of Birth
Name of insurance company
Group #

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Lubbock Office
4601 50th St Suite 206
Lubbock, TX  79414
Phone: 806-792-8116
Lamesa Office
1009 North 7th
Lamesa, TX  79331
Phone: 806-872-2865
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