Scholarships for Orthodontic Care to Children
Confidential Patient Information
Confidential Responsible Party Information
Mailing address (if different from residence)
Previous Address (if less than three years)
dental insurance information
If you have orthodontic insurance coverage or would like to find out, please provide your insurance information below. We will determine the amount of your insurance benefit by the time you arrive for your exam.
First policy holder
Second policy holder
Please complete the fields below if you have dual coverage.
Authorization to Share Information
Please answer all questions for the patient if they are a minor, or for yourself if you are the patient.
Do you have any of the following habits?
Thumb/Finger suckingTongue thrustSpeech ProblemsNail bitingMouth breathingLip sucking/biting
Have you ever...
Have you ever had any of the following:
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.
Do you currently, have you ever taken any Bisphosphonate medications?(Acetonel/Risedronate,Aredia/Pamidronate,Didronel/Etidronate,Fosamax/Alendronate,Skelid/Tilndronate, Zoledronic Acid)
Please check any of the following that you have had or currently have:
Abnormal bleedingADHDAnemiaArthritisAsthmaAustinBone DisordersCongenital Heart DefectDiabetesDizzinessEpilepsyGastrointestinal DisordersHeart ProblemsHeart MurmurHepatitis/Liver problemsHerpesHigh Blood PressureHIV / AIDSPnuemoniaKidney ProblemsLearning disabilitiesNervous DisordersProlonged BleedingRadiation / ChemotherapyRheumatic FeverSyndromes of Systemic NatureThyroid Related DisordersTuberculosisTumer / Cancer