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Virtual Smile Consult!
Home
About
Patients
New Patients
Life With Braces
Emergencies
Treatments
By Age
Invisalign
Braces
Retainers
Whitening
TADs
FAQs
Contact
Virtual Smile Consult!
New Patient Form
Please fill out the following information before arriving for your initial consultation.
Today's Date
MM
DD
YYYY
About You
Sex
Male
Female
Name
First Name
Last Name
Birth Date
MM
DD
YYYY
Social Security #
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home #
(###)
###
####
Cell #
(###)
###
####
Email
Employer
Employer Address
Occupation
Marital Status
Single
Married
Separated
Divorced
Widowed
Partnered
Other Family Members Seen At This Office
General Dentist
General Dentist #
(###)
###
####
Physician
Physician #
(###)
###
####
Spouse's Information
Spouse's Name
First Name
Last Name
Spouse's Birth Date
MM
DD
YYYY
Spouse's Home #
(###)
###
####
Spouse's Cell #
(###)
###
####
Spouse's Social Security #
xxx-xxx-xxxx
Spouse's Email
Spouse's Employer
Primary Insurance Information
Name of Person Carrying Insurance
Address
Birth Date
MM
DD
YYYY
Social Security #
Employer
Dental Insurance Co.
Address
Group #
ID #
Secondary Insurance Information
Name of Person Carrying Insurance
Address
Birth Date
MM
DD
YYYY
Social Security #
Employer
Dental Insurance Co.
Address
Group #
ID #
Dental History
What are the main concerns that you would like orthodontics to accomplish?
Have you ever been evaluated or had orthodontic treatment?
Yes
No
Have there been any injuries to the face, mouth, teeth or chin?
Yes
No
List any musical instruments played:
Have adenoids or tonsils been removed?
Yes
No
Do you have any pain/tenderness in the jaw joint?
Yes
No
Have you experienced any of the following?
Clenching/Grinding Teeth
Mouth Breathing
Nail Biting
None
Medical History
Select all that apply:
Allergies to drugs
Allergy to anesthetics
Heart ailments
Artificial heart valve
Heart attack
Congenital heart defect
Heart surgery
Mitral valve prolapse
Pacemaker
High blood pressure
Rheumatic fever
Malignancies
Cancer-chemotherapy
Radiation therapy
Abornomal bleeding
Alcohol / Drug abuse
Anemia
Arthritis
Joint replacement
Asthma
Blood transfusion
Colitis
Diabetes
Eye disorders
HIV / Aids
Hay fever
Hepatitis A / B
Kidney problems
Liver disease
Lymes
Neurological problems
Pain in jaws
Psychiatric problems
Seizures
Sinus problems
Stroke
Surgery
Taken fen / phen
Taken Fosomax / Bisphosphonate
Thyroid problems
Tonsilectomy
Tuberculosis
Ulcers / GI disturbances
Venereal disease
Oral habits
Clenching / Grinding
Fluoride supplements
Periodontal treatment
Orthodontia
Swelling in mouth
Allergies:
Aspirin
Codeine
Anesthetics
Erythromycin
Latex
Metals
Penicillin
If female, please answer the following:
On birth control
Pregnant
Nursing
Smoke / Use tobacco
Need to premedicate for dental treatment
Medications
Please list.
Is there any disease or problem that you think this office should know about that is not covered above?
Yes
No
If yes, please describe below:
Thank you!
