Patient Information Form | Allen Orthodontist

Patient Information

* First Name: (Required)

* Last Name: (Required)

Nickname:

E-mail:

Patient Address:

Zip:

Telephone:

Birth Date:

Age:

Gender: Male Female

School / Employer's Name:

Grade / Position:

Interest/Sports:

Primary Responsible Party

* Responsible Party Name: (Required)

DOB:

Address:

Zip:

Telephone:

Employer/Address:

Telephone:

Social Security Number:

Primary Party Email Address:

Secondary Responsible Party

Secondary Responsible Party Name:

DOB:

Address:

Zip:

Telephone:

Employer/Address:

Telephone:

Social Security Number:

Secondary Party Email Address:

Present Dentist:

Reason For Consultation:

Any disease, problems, or allergies not mentioned above?

Current Medications?

Females: Have you started Menstruating?

At what age?

Have wisdom teeth been extracted?

Any face, mouth or teeth injuries?

Does the patient normally breathe through the mouth while awake or asleep?

Do gums bleed when brushed or flossed?

When was your last dental cleaning and check up?

Any pending dental work?:

Have you had previous orthodontic treatment?

Are there any missing or extra teeth?

Have the Tonsils and adenoids been removed?

Any oral habits such as thumb-sucking or nail-biting?

Names and Ages of Brothers & Sisters:

Insurance Information

(Please fill out completely so we may properly file your insurance)

Primary Orthodontic Insurance:

Insurance Telephone:

Member ID Number:

Group Number:

Policy Holder's Date of Birth:

Secondary Orthodontic Insurance:

Insurance Telephone:

Member ID Number:

Group Number:

Policy Holder's Date of Birth:

Signature

Relationship To Patient:

Date: