1 Patient Information2 Insurance Information3 Health History4 Present or Past Conditions5 Dental History First Name*Last Name*Address - Street Address*City*State*Zip Code*Country*Phone*DOB*Email* Current or last dentist*If none, please type n/a belowInterested in:* Invisalign (clear aligners) Incognito (hidden braces) Ceramic Braces (clear brackets) Retainers Other How did you find us?*DentistFriend/FamilyFacebookGoogleYelpWalk-inReason for consultation:*CrowdingSpacingTMJHave you had a previous consultation with another orthodontist?* Yes No Primary Insurance Information*If none, please type n/a in each box below Insurance Company Name Primary Subscriber Name Primary Subscriber ID Primary Subscriber DOB / SSN Employer/ Group Number Secondary Insurance Information*If none, please type n/a in each box below Insurance Company Name Primary Subscriber Name Primary Subscriber ID Primary Subscriber DOB / SSN Employer/ Group Number Are you in good health?*YesNoDoes the patient have any history of major illness??*YesNoHas the patient ever been under the care of a physician for illness?*YesNoHas the patient ever been hospitalized? If yes, please select other*NoDate of last examination by physician:* Do you bruise easily?*YesNoHas the patient had their tonsils or adenoids removed?*YesNoPlease list the medications that you take or have taken:*Or type n/a if none Heart murmur*YesNoRheumatic fever*YesNoHigh blood pressure*YesNoLow blood pressure*YesNoHepatitis*YesNoDiabetes*YesNoKidney disease*YesNoAsthma*YesNoFainting*YesNoTuberculosis*YesNoPheumonia*YesNoNervousness/ anxiety*YesNoCancer treatment*YesNoSinus trouble*YesNoEpilepsy*YesNoArthritis*YesNoAnemia/ blood disease*YesNoThyroid/ parathyroid problems*YesNoSiezures*YesNoFrequent headaches*YesNoPhyschiatric care*YesNoTumors/ growths*YesNoBone disorders*YesNoEndocrine problems*YesNoImmune system problems*YesNoProlonged bleeding*YesNo Does the patient have any allergies to:* Local anesthetics Sulfa drugs Aspirin penicillin/ other antibiotics Sedatives / sleeping pills Iodine Codeine/ other narcotis Other None of the above Date of patient's last dental examination or treatment* Has the patient had any problems with previous dental treatment?*YesNoHave there been any injuries to patient's face, mouth, or teeth?*YesNoHas patient ever sucked a thumb or fingers?*YesNoDoes patient have any speech problems?*YesNoDoes patient clench or grind teeth?*YesNoIs there any clicking, popping when patient chews?*YesNoIs there any numbness in patient's face, mouth, or jaw?*YesNoNameThis field is for validation purposes and should be left unchanged.