New Patient Digital Form Patient Information "*" indicates required fields First Name*Middle NameLast Name*I prefer to be called (Nickname)GenderMaleFemaleOtherBirth date (MM-DD-YYYY)* MM slash DD slash YYYY Cell/Other Phone*Home PhoneAddress, City, Zip*Whom may we thank for referring you to our office? (dentist's name, family, friend, facebook, google, website, etc.)*Other family members seen by usPatient's school (if minor)Responsible Party InformationFull NameRelationship to PatientHome Phone (if different)Cell/Other PhoneEmail Address Mailing Address (if different)Dental InsuranceName of Dental Insurance CompanyInsurance Company AddressInsurance Phone NumberPolicyholder's address, if different than PatientPolicyholder's First and Last NamePolicyholder's Date of Birth MM slash DD slash YYYY Subscribers ID, Member ID, OR Social SecurityPlan or Group NumberSubscriber / Policy IDGenderMaleFemaleOtherPerson To Contact In Case of an EmergencyNamePhoneDental HistoryGeneral Dentist*Date of Last Visit MM slash DD slash YYYY Chief orthodontic complaint*Please briefly answer/describe any of the following which apply to you.Previous orthodontic treatment Yes No Comment:History of dental/ facial trauma? Yes No Comment:Broken/Missing teeth? Yes No Comment:Jaw/Joint problems? Yes No Comment:Locking, clicking, grinding, popping? Yes No Comment:Do you have any type of thumb or tongue habit? Yes No Comment:Comment:Financial ExpectationsTo help meet your expectations, we ask that you fill out this portion so we can customize your treatment options. Investing in a smile is one of the best choices you can make! If treatment is recommended for you/your child, what is your ideal down payment? $400-$499 $500-$749 $750+ I would like to pay in full and receive a courtesy discount I have an HSA or FSA I would like to use If treatment is recommended for you/your child, what is your ideal monthly payment? $100-$199 $200-$299 $300-$399 I have an HSA or FSA I would like to use If treatment is recommended for you/your child, what is your desired time frame to begin this exciting journey? I would like to get started today I would like to get on the schedule I am shopping around for other opinions I am unsure Medical HistoryPlease fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential. Please check any of the following which apply to you, and add any relevant comments.PhysicianDate of Last Visit MM slash DD slash YYYY Are you taking any medications? Yes No CommentList any history of serious illness, accident, or other conditions Yes No For Females only: Are you currently Pregnant? Yes No CommentsPlease check any of the following that you have had or currently have:Artificial Joint Replacement/Implant Yes No Abnormal Bleeding/Hemophilia Yes No Anemia Yes No Arthiritis Yes No Asthma or Hay Fever Yes No Bone Disorders Yes No Diabetes Yes No Dizziness Yes No Epilepsy Yes No Gastrointestinal Disorders Yes No Heart Problems Yes No Hepatitis/Liver Problems Yes No High Blood Pressure Yes No HIV/AIDS Yes No Kidney Problems Yes No Latex Allergy Yes No Nervous Disorders Yes No Radiation/Chemotherapy Yes No Tumor or Cancer Yes No Tuberculosis Yes No Are there any medical conditions we have not discussed that you feel we should be aware of? Yes No Digital SignatureTo be signed by the patient or responsible party. The signature verifies that the information provided on this patient history form is current and accurate.Signature of Patient/ParentDate MM slash DD slash YYYY Section Break