Patient Registration Form

Patient Sign-in
New patient Registration
Medical History
Medical history
Dental History
Dental history
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Patient Information


First Name *
Last Name*

Gender* Male Female

Preferred Name
Birth Date *
How did you hear about our office? *
If referred, by who?
Special sports or hobbies
School
Other family members and their birth dates

Please complete information below:

Primary Responsible Party

(Accompanying adult or self)*

Self Mother Father Other
Orthodontic insurance?* Yes No
First Name *
Last Name*
Occupation
Employer
How Long
SS#

Marital status* : Married Single Divorced Separated Widowed

Email
Current Address *
Apt #
Cell Phone *
City *
State *
Zip *

If at current less than 3 years

Cell Phone
Former Address
Apt #
Work Phone
City
State
Zip

Secondary Responsible Party

Self Mother Father Other
Orthodontic insurance ? Yes No
First Name
Last Name
Occupation
Employer
How Long
SS#

Marital status: Married Single Divorced Separated Widowed

Email
Current Address
Apt #
Cell Phone
City
State
Zip

If at current less than 3 years

Cell Phone
Former Address
Apt #
Work Phone
City
State
Zip

If the patient is under the age of 18 and/or is not the financially responsible party of the account, who do they reside with?

The child resides with:

Mother & Father Father Mother Other:

  • I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence.
  • I understand that where appropriate, credit bureau reports may be obtained.
  • I authorize the dental staff to perform the necessary orthodontic services may be necessary for the initial consultation.
  • I authorize that photos taken may be used in journal articles, promotional materials, our website/facebook pages, and are the property of The Big Smile Orthodontics.
  • I authorize release of any information relating to any Insurance claim.
  • I authorize payment directly, where applicable, to the office of The Big Smile Orthodontics.
  • I consent to the dental practice using my cell phone number to contact me regarding appointments, treatment, insurance, and my account.

SIGNATURE (parent or guardian if under 18)

(Please click below to draw/upload sign)

Please complete information below:

Appt. Date
At

Do you have primary insurance ?

Yes     No

Do you have secondary insurance ?

Yes     No

PRIMARY POLICYHOLDER INFORMATION


Relationship to Patient
Name *
(Policyholders Name)
ID # or SS # *
(ID# is not the same as group # • BCBS accepts ID# ONLY. • INS cards without ID# use SS#)
Date of birth *
Employer *
Hourly     Salary
Dental Ins. Company *
Ins. Phone #
Ins. Address
City
State *
Zip

* Note: Medical Insurance does not cover orthodontic treatment



SECONDARY POLICYHOLDER INFORMATION


Relationship to Patient
Name *
(Policyholders Name)
ID # or SS # *
(ID# is not the same as group # • BCBS accepts ID# ONLY. • INS cards without ID# use SS#)
Date of birth *
Employer *
Hourly     Salary
Dental Ins. Company *
Ins. Phone #
Ins. Address
City
State *
Zip

* Note: Medical Insurance does not cover orthodontic treatment



Dental Information


What is your main reason for seeing an orthodontist? ( check all that apply )*
   Crooked teeth    
   Crowding    
   Spacing    
   Missing or extra teeth    
   Overbite    
   Don’t like smile    
   Bad bite    
   Crossbite   
   Jaw pain    
   Other    
Please explain *


Are you concerned about the appearance of teeth?*
No     Yes
Are you frightened or anxious about treatment?*
No     Yes
Would you mind wearing braces if necessary?*
No     Yes
Invisible braces?
No     Yes
What aspect of orthodontic treatment are you most concerned with?*
Esthetics    
Discomfort    
Cost    
Quality    
Time    
Any missing or extra teeth?
Any sores, lumps or irritated areas in the mouth?*
No     Yes
Any previous orthodontic treatment?
No     Yes
When?
Have other members of the family had orthodontic treatment?
No     Yes
If so, whom?
Are they satisfied with the results?
No     Yes
Any previous treatment for?
TMJ     Gum Disease
By whom?
Why?
Is this a second opinion?
No     Yes
Who was the first?
Why?
Any injuries to face, head, mouth or teeth?
No     Yes
When?
Pain in or near ears?
No     Yes
When?
Headaches, facial pain or jaw joint problems?
No     Yes
If so, please explain
Are there any speech problems?
No     Yes
Please explain

About patient's home care

Please rate oral hygiene*
Good     Fair     Poor
Brush teeth daily?*
No     Yes
Floss teeth?*
No     Yes
How often?

Any history of these habits?

Mouth Breathing    
Nail/Lip biting    
Leaning on chin or face    
Grinding of teeth    
Thumb sucking    
Snoring    
Other    
General Dentist – Dr
Date of last visit
Any other information that would be helpful?

Medical Information


Overall medical health*
Good     Fair     Poor
Smoker     Non Smoker    
Is there a tendency for
Ear Infections   Colds   Sore throats

Any history of:


Asthma*
No     Yes
Hepatitis*
No     Yes
Anemia*
No     Yes
Allergies*
No     Yes
Diabetes*
No     Yes
Blood Disease*
No     Yes
Rheumatic Fever*
No     Yes
Bone Disorders*
No     Yes
Cold sores/Herpes*
No     Yes
Epilepsy*
No     Yes
Heart disease*
No     Yes
AIDS/HIV*
No     Yes
Any other medical problems we should be aware of?


Is pre-medication needed before dental treatment?*
No     Yes     Uncertain    
If so why?
Have tonsils and adenoids been removed?*
No     Yes    
If so, when?
If adolescent female, has menstrual cycle started?
No     Yes    
If so, when?
List any drugs or medications being taken.
List any allergies or drug sensitivities
Physician - Dr
Date of last visit
(I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.)

SIGNATURE

(Please click below to draw/upload sign)

Orthodontic Acquaintance Form


Patient Information


First Name:    Last Name: 

Male
Female
Preferred name:    Birth date: 

How did you hear about our office?    If referred, by who? 
Other family members and their birth dates: 

Please complete information below:

Primary Responsible Party

(Accompanying adult or self)


Self Mother Father Other Orthodontic insurance? Yes No
First Name:    Last Name: 
Occupation:    Employer:  How Long: 
SS#:    Marital status: Married Single Divorced Separated Widowed
Email:    Current Address:  Apt #: 
Home Phone:    City:  State:  Zip: 

If at current less than 3 years

Cell Phone:    Former Address:  Apt #: 
Work Phone:    City:  State:  Zip: 

Secondary Responsible Party

(Accompanying adult or self)


Self Mother Father Other Orthodontic insurance? Yes No
First Name:    Last Name: 
Occupation:    Employer:  How Long: 
SS#:    Marital status : Married Single Divorced Separated Widowed
Email:    Current Address:  Apt #: 
Home Phone:    City:  State:  Zip: 

If at current less than 3 years

Cell Phone:    Former Address:  Apt #: 
Work Phone:    City:  State:  Zip: 

If the patient is under the age of 18 and/or is not the financially responsible party of the account, who do they reside with?


The child resides with:   Mother & Father Father Mother Other:

  • I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence.
  • I understand that where appropriate, credit bureau reports may be obtained.
  • I authorize the dental staff to perform the necessary orthodontic services may be necessary for the initial consultation.
  • I authorize that photos taken may be used in journal articles, promotional materials, our website/facebook pages, and are the property of The Big Smile Orthodontics.
  • I authorize release of any information relating to any Insurance claim.
  • I authorize payment directly, where applicable, to the office of The Big Smile Orthodontics.
  • I consent to the dental practice using my cell phone number to contact me regarding appointments, treatment, insurance, and my account.

 
 
August 14, 2018
()
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Orthodontic Insurance Information


Appt. Date:    at 

PATIENT NAME        Date of Birth 

Primary Policyholder Information

NAME  
(Policyholders Name)
ID # or SS # 
(ID# is not the same as group # • BCBS accepts ID# ONLY. • INS cards without ID# use SS#)

Date of birth   Relationship to Patient 

Employer  
Hourly     Salary

Dental Ins. Company   Ins. Phone #  

Ins. Address   City   State   Zip  
* Note: Medical Insurance does not cover orthodontic treatment

Secondary Policyholder Information

NAME  
(Policyholders Name)
ID # or SS # 
(ID# is not the same as group # • BCBS accepts ID# ONLY. • INS cards without ID# use SS#)

Date of birth   Relationship to Patient 

Employer  
Hourly     Salary

Dental Ins. Company   Ins. Phone #  

Ins. Address   City   State   Zip  
* Note: Medical Insurance does not cover orthodontic treatment


Medical / Dental Information

Patient Name   First   Last  

Dental Information

What is your main reason for seeing an orthodontist? ( check all that apply )

  Crooked teeth   Crowding   Spacing   Missing or extra teeth   Overbite
  Don’t like smile   Bad bite   Crossbite   Jaw pain   Other

Please explain  

Are you concerned about the appearance of teeth? No     Yes Any previous treatment for? TMJ     Gum Disease
Are you frightened or anxious about treatment? No     Yes By Whom?  
Would you mind wearing braces
if necessary?
No     Yes Why?  
Invisible braces? No     Yes Is this a second opinion?   No     Yes
What aspect of orthodontic treatment are you most concerned with? Who was the first?  
Esthetics  Discomfort     Cost    
Quality     Time     Why?  
Any missing or extra teeth?   Any injuries to face, head, mouth
or teeth?  
No     Yes
Any sores, lumps or irritated
areas in the mouth?
No     Yes When?  
Any previous orthodontic treatment? No     Yes Pain in or near ears?   No     Yes
When?   When?  
Have other members of the family had orthodontic treatment?
No     Yes Headaches, facial pain or jaw
joint problems?  
No     Yes
If so, whom?   If so, please explain?  
Are they satisfied with the results?   No     Yes Are there any speech problems?   No     Yes
About patient’s home care

Please explain  
Please rate oral hygiene    Good     Fair     Poor Any history of these habits?

Brush teeth daily?    No     Yes Mouth Breathing   Nail/Lip biting Leaning on chin or face  
Floss teeth?     No     Yes Grinding of teeth   Thumb sucking   Snoring  
How often?   Other  

General Dentist – Dr   Date of last visit  

Any other information that would be helpful?


Medical Information

Overall medical health     Good     Fair     Poor Smoker     Non Smoker    

Is there a tendency for     Ear Infections   Colds   Sore throats

Any history of:

Asthma  No     Yes Diabetes  No     Yes
Cold sores/Herpes  No     Yes Hepatitis  No     Yes
Blood disease  No     Yes Epilepsy  No     Yes
Anemia  No     Yes Rheumatic Fever  No     Yes
Heart disease  No     Yes Allergies  No     Yes
Bone Disorders  No     Yes AIDS/HIV  No     Yes
Any other medical problems we should be aware of?

Is pre-medication needed before dental treatment? No     Yes     Uncertain     If so why?

Have tonsils and adenoids been removed? No     Yes     If so, when?

If adolescent female, has menstrual cycle started? No     Yes     If so, approximately when?

List any drugs or medications being taken.
List any allergies or drug sensitivities

Physician - Dr. Date of last visit

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

 
 
August 14, 2018
()
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
PRIVACY POLICY

I acknowledge that I have reviewed the Privacy Policy Notice for The Big Smile Orthodontics.
( Parent / Guardian name - if patient is under 18 )

 
 
August 14, 2018
()
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

In case you do not agree to sign this form, our office must indicate why you declined to do so.
Reason for Parent / Guardian / Patient’s refusal to sign

 
Privacy director’s Signature DATE & IP ADDRESS
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