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Patient Request Form (EN)
Patient Information
Patient Full Name
Patient Address
Birth Date
MM slash DD slash YYYY
Gender
Male
Female
Patient's Dentist
Patient's Phone
Dentist's Phone
Whom do we thank for the Referral?
Other family members seen by us?
RESPONSIBLE PARTY INFORMATION
Responsible Party Name
Relationship to patient
Responsible Party Address
Responsible Party Phone Number
DENTAL INSURANCE INFORMATION
Name of insured
Birth Date
MM slash DD slash YYYY
Relationship to patient
Employer of Insured
ID Number of insured
Name of INS company
Phone # of Ins Company
Group number
HEALTH HISTORY
MEDICAL HISTORY: Please select if you have / hAVE NOT
ADHD/ADD
Asthma
Reached Puberty
Heart Trouble
Heart Murmur
Artificial Joints
Joint Swelling
Arthritis
Prolonged Bleeding
Endocrine / Thyroid / Kidney Problems
Hepatitis or Liver Problems
Diabetes
AIDS/HIV
Epilepsy
Tonsils removed
Are you pregnant?
Seasonal Allergies
Drug Allergies
If female, has patient started menstruation?
Tick if yes
If yes, When did menstruation start?
Please list details of tonsils removed
*
Please list details of pregnancy
*
List Drug Allergies
*
Allergies: Latex / Nickel / Nuts
*
Latex
Nickel
Nuts
None
Are you presently under a physician’s care?
*
Yes
No
If yes, what is the reason?
Last yearly physical:
Physician Name:
Physician Name:
Any medical conditions that you should make us aware of ?
Please check if you have /had
Date of last cleaning
MM slash DD slash YYYY
Date of last cleaning
*
Yes
No
Past history of gum disease
*
Yes
No
Any treatment?
Any Injuries to face, mouth, teeth?
*
Yes
No
Any clenching/grinding?
*
Yes
No
Any Habits? tongue, thumb, finger, lip sucking, others?
*
Yes
No
Please List
Any pain, popping, or locking on opening or closing jaw?
*
Yes
No
Any muscle tenderness or stiffness in the
*
Jaw
Neck
Any previous treatment for TMJ or jaw problems?
*
Yes
No
Frequent Headaches
*
Yes
No
Mouth Breathing
*
Yes
No
Any missing teeth or additional teeth?
*
Yes
No
Any previous orthodontic evaluation/treatment?
*
Yes
No
At what age?
Completed?
*
Yes
No
Reason for treatment
Name of Orthodontist
NOTES
Patient/Responsible Party
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