to the Orthodontist - Guajardo Orthodontics

to the Orthodontist
The bene ts of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain optimal oral
health. Please
out this form completely. The better we communicate, the better we can care for you!
About You
Orthodontic Insurance
Today’s Date:
Primary
Email Address:
Orthodontic Coverage?
Name:
Insurance Co. Name:
Birthdate:
/
/
SS#:
Age:
Ins. Co. Phone#: (
Male
Yes
)
Insured’s Name:
Female
Home Address:
No
Insured’s Birthdate:
Relation:
/
/
SS#:
Please give your ins. card to the receptionist for a copy!
Single
Married
Divorced
Widowed
Hm#: (
)
Cell/Other#: (
Wk#: (
)
Ext:
Separated
)
DL#:
Patient’s Health History
Patient Dentist:
Phone #: (
)
Last Cleaning:
Employer:
Has the patient had previous Orthodontic;
Who referred you?
Consultations?
Other family members seen by us:
If so please list where:
Yes
No Treatment?
Yes
No
Previous/Present Dentist:
Present drugs/medications:
Person Responsible for Account:
Spouse Information
List any allergies or drug sensitivity:
His/ Her Name:
Birthdate:
/ /
Phone #: ( )
Relative/Friend not living with you:
His/ Her Name:
Phone #: (
)
Relation:
Our office is HIPAA compliant and is committed
to meeting or exceeding the standards of infection
control mandated by OSHA, the CDC and the ADA.
Medical History
Do you have a personal physician?
Dental History
Yes
No
What are the main concerns that you would like
Physician’s Name:
Phone #: (
)
orthodontics to accomplish?
Date of last visit:
Your Current physical health is:
Good
Fair
Poor
Are you currently under the care of a physician?
Yes
Are you happy with the way your smile looks?
No
Please explain:
If not, what would you change?
Do you smoke or use any tobacco?
Yes
No
Have you had any metal rods, pins or implants?
Yes
No
Have you ever taken Phen-Fen?
Have you ever had a serious/difficult problem associated
with any previous dental work?
Also known as Redux or Pondimin.
Yes
No
Yes
in your jaw joint (TMJ/TMD)?
For Women: Are you taking birth control pills?
Yes
No
Are you nursing?
Have youeverhad any of the following
Diseases/ Medical problems:
Yes No
Yes No
Abnormal Bleeding/Hemophilia
AIDS
Alcohol/Drug Abuse
Anemia
Arthritis
Artificial Bones/Joints/Valves
Asthma
Blood Transfusion
Cancer/Chemotherapy
Colitis
Congenital Heart Defect
Diabetes
Difficulty Breathing
Emphysema
Epilepsy
Fainting Spells
Frequent Headaches
Glaucoma
Hay Fever
Heart Attack / Surgery
Heart Murmur
Hepatitis
Yes
No
Do you or have you ever experienced pain/ discomfort
If so, when?
Are you pregnant?
No
Yes
No
Your current dental health is?
Yes
No
Good
Fair
Yes
No
Poor
Week #:
Do you still have wisdom teeth?
Yes
Have you ever had an injury to your: (please circle)
No
●
Mouth
Teeth
Chin
Do you have any speech problems?
Herpes/Fever Blisters
High Blood Pressure
HIV
Hospitalized for any reason
Kidney Problems
Liver Disease
Low Blood Pressure
Lupus
Mitral Valve Prolapse
Pacemaker
Psychiatric Problems
Radiation Treatment
Rheumatic/Scarlet Fever
Seizures
Shingles
Sickle Cell Disease/ Traits
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis
Ulcers
Veneral Disease
Please list any serious medical condition(s) that you have ever had:
I understand that the information that I have given today is correct
to the best of my knowledge. I also understand that this
information will be held in the strictest confidence and that it is
my responsibility to inform this office of any changes in my
medical status. I authorize the dental staff to perform any
necessary dental services that I may need during diagnosis and
treatment, with my informed consent. This office reserves the right
to verify the credit status of potential patients and/or parents of
patients prior to extending credit for treatment fees and may, at
the discretion of the office, use the services of one or more credit
reporting services.
I will accept responsibility for any bill incurred for Orthodontic
treatment.
Signature _____________________ Date: ____________
Thank you for visiting the o
of Dr. Guajardo it was a pleasure
seeing you and we look forward to seeing you again!