TO THE ORTHODONTIST1 he benefits of a happy, healthysmile are immeasurable! A beautifulsmile is a wonderful asset.

ABOUT YouToday's Date:.

E-Mail Address:

Name:

I prefer to be called:

Ml MR MRS MS DR

D Male D Female

Birthdate: / / Age: SS #:

Home Address:

STATE ZIP

D Single D Married D Divorced D Widowed D Separated

Hm #: ( ) Cell/Other #:

Wk#:( I Ext: DL#:

Employer:

Employer's Address:

How long there? Occupation: _

Where & when are best times to reach you?

Whom may we Thank for referring you?

Other family members seen by us:

General Dentist:

Last Visit Date:

His / Her Name:

Employer:

Wk#:( )_

Cell:

Ext: SS#:

Birthdate: / /

Person Responsible for Account:

Wk #: ( ) Ext: Hm #: (

Billing Address:

Relation: _

Employer:

_SS#:

DL#:

Please fill out this form completely.The better we communicate, the

better we can care for you.

Primary

Orthodontic Coverage: D Yes D No Dental Coverage: E Yes D No

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #: I

Group # (Plan, Local or Policy #):

Insured's Name: Relation:

Insured's Birthdate: / / Insured's ID #:

Insured's Employer:

Secondary

Orthodontic Coverage: D Yes D No Dental Coverage: D Yes D No

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #: I

Group # (Plan, Local or Policy #):

Insured's Name: Relation:

Insured's Birthdate: / / Insured's ID #:

In the event of an emergency, is there someone

who lives near you that we should contact?

His / Her Name: Relation:

Wk#:l

Do you have a personal physician? D Yes D No

Physician's Name:

Phone #: ( ) Date of last visit:

CONTINUED ON BACK

MEDICAL HISTORY continued

Your current physical health is: D Good D Fair D Poor

Are you currently under the care of a physician? D Yes D No

Please explain:

Are you taking any prescription / over-the-counter drugs?

Please list each one:

lYes I No

For Women: Are you using a prescribed method of birth control? D Yes D No

Are you pregnant? D Yes C3 No Week #:

Are you nursing? D Yes H No

Have you ever had any of the followingdiseases or medical problems?

Y N Abnormal BleedingY N AnemiaY N Artificial Bones /Joints /ValvesY N Asthma /ArthritisY N Blood TransfusionY N Cancer / ChemotherapyY N Congenital Heart DefectY N DiabetesY N Difficulty BreathingY N Drug /Alcohol AbuseY N EmphysemaY N Epilepsy / Seizures / FaintingY N Fever Blisters / HerpesY N GlaucomaY N Heart Attack /StrokeY N Heart MurmurY N Heart Surgery / Pacemaker

Y N HemophiliaY N HepatitisY N High / Low Blood PressureY N HIV+/AIDSY N Hospitalized for Any ReasonY N Kidney ProblemsY N Mitral Valve ProlapseY N Psychiatric ProblemsY N Radiation TreatmentY N Rheumatic / Scarlet FeverY N Severe / Frequent HeadachesY N ShinglesY N Sickle Cell Disease /TrailsY N Sinus ProblemsY N Tuberculosis (TB)Y N Ulcers / ColitisY N Venereal Disease

Please list any serious medical condition(s) that you have ever had:

Are you allergic to any of the following?

Y N Aspirin

Y N Any Metals/Plastics

Y N Codeine

Y N Dental Anesthetics Y

Y N Erythromydn Y

Y N Latex Y

N Penicillin

N Tetracycline

N Other

Please list any other drugs/materials that you are allergic to:

DENTAL HISTORY

What are the main concerns that you would like orthodontics to accomplish?

Have you ever had or been evaluated for orthodontic treatment? D Yes D No

Have you ever had a serious / difficult problem associatedwith any previous dental work? D Yes D No

Do you now or have you ever experienced pain /discomfort in your jaw joint (TMJ / TMD)? D Yes D No

Your current dental health is: D Good D Fair D Poor

Do you like your smile? D Yes D No Gums ever bleed? D Yes D No

Have you ever had an injury to your: Mouth Teelh Chin (Please circle)

Do you have any speech problems?

Do you generally breathe through your mouth? D Yes D NoIf yes, please circle: While Awake? While Asleep?

Do you have any missing or extra permanent teeth? D Yes D No

Have you ever taken Fosamax, or any other bisphosphonate? D Yes D No

Have you ever taken Phen-Fen? D Yes D No

Do you smoke or use tobacco in any form? D Yes D No

understand that the information that I havegiven today is correct to the best of my

knowledge. I also understand that this informationwill be held in the strictest confidence and it is myresponsibility to inform this office of any changes in mymedical status. I authorize the dental staff to perform anynecessary dental services that I may need during diagnosisand treatment with my informed consent.

Signature Date

Thank you for filling out this form completely.

This office reserves the right to verify the credit status of potential patientsand / or parents of patients prior to extending credit for treatment fees and may, atthe discretion of the office, use the services of one or more credit reporting services.

If this office accepts insurance, I understand that I am responsible for payment of services ren-dered and also responsible for paying any co-payment and deductibles that my insurance doesnot cover. I hereby authorize payment of the group insurance benefits (otherwise payable tome) directly to this office.

Signature Date Signature Date

Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY

I verbally reviewed the medical / dental information above with the patient named herein. Initials:

Doctor's Comments:

Date:

FORM #ORTHO-2A CLASSIC ORTHO www.informsonline.com 1 informs i-300-722-4884