CARY, NC

(919) 233-0668

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Home
About
For Patients
Orthodontics
Treatment
Blog
Appointment Request
Contact

Home
About
For Patients
Orthodontics
Treatment
Blog
Appointment Request
Contact

Home
About
For Patients
Orthodontics
Treatment
Blog
Appointment Request
Contact

Home
About
For Patients
Orthodontics
Treatment
Blog
Appointment Request
Contact

Home
About
For Patients
Orthodontics
Treatment
Blog
Appointment Request
Contact

Contact

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Office Visits
Office Tour
Financial Information
Before and After
Orthodontic FAQs
Testimonials
Patient Forms

Patient Information

"*" indicates required fields

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First Name*

Middle Name

Last Name*

I prefer to be called (Nickname)

Gender

Birth date (MM-DD-YYYY)*

MM slash DD slash YYYY

Cell/Other Phone*

Home Phone

Address, 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 us

Patient's school (if minor)

Responsible Party Information

Full Name

Relationship to Patient

Home Phone (if different)

Cell/Other Phone

Email Address

Mailing Address (if different)

Dental Insurance

Name of Dental Insurance Company

Insurance Company Address

Insurance Phone Number

Policyholder's address, if different than Patient

Policyholder's First and Last Name

Policyholder's Date of Birth

MM slash DD slash YYYY

Subscribers ID, Member ID, OR Social Security

Plan or Group Number

Subscriber / Policy ID

Gender

Person To Contact In Case of an Emergency

Name

Phone

Dental History

General 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

Comment:

History of dental/ facial trauma?

Yes

Comment:

Broken/Missing teeth?

Yes

Comment:

Jaw/Joint problems?

Yes

Comment:

Locking, clicking, grinding, popping?

Yes

Comment:

Do you have any type of thumb or tongue habit?

Yes

Comment:

Financial Expectations

To 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 History

Please 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.

Physician

Date of Last Visit

MM slash DD slash YYYY

Are you taking any medications?

Yes

Comment

List any history of serious illness, accident, or other conditions

Yes

For Females only: Are you currently Pregnant?

Yes

Comments

Please check any of the following that you have had or currently have:

Artificial Joint Replacement/Implant

Yes

Abnormal Bleeding/Hemophilia

Yes

Anemia

Yes

Arthiritis

Yes

Asthma or Hay Fever

Yes

Bone Disorders

Yes

Diabetes

Yes

Dizziness

Yes

Epilepsy

Yes

Gastrointestinal Disorders

Yes

Heart Problems

Yes

Hepatitis/Liver Problems

Yes

High Blood Pressure

Yes

HIV/AIDS

Yes

Kidney Problems

Yes

Latex Allergy

Yes

Nervous Disorders

Yes

Radiation/Chemotherapy

Yes

Tumor or Cancer

Yes

Tuberculosis

Yes

Are there any medical conditions we have not discussed that you feel we should be aware of?

Yes

Digital Signature

To 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/Parent*

Date*

MM slash DD slash YYYY

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Contact Us

(919) 233-0668
540 New Waverly Pl # 110, Cary, NC 27518
Get directions
Monday - Thursday:
8 am - 5 pm with lunch from 1 pm - 2 pm
info@bernsteinortho.com

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North Carolina Association of Orthodontists

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