Payment Calculator
Patient Forms
Confidential Patient Information
First Name * Preferred Name(Nickname)
Last Name* Date of Birth*
Street Address*
City*
State/Province*
Postal Code*
Phone Number*
If patient is a minor,give parent's or guardians's name*
Email Address*
Gender* MaleFemale
School*
Grade*
Please list your interests and sports*
Names and ages of siblings*
How did you hear about our office,or whom may we thank for referring you?*
Confidential Responsible Party Information
First Name * Relationship to Patient *
Last Name * Marital Status *
Residence
Street Address * City *
How long at this address(in years)? * State/Province *
Zip/Postal Code *
Mailing address (if different from residence)
Street Address
City
State/Province
Zip/Postal Code
Previous Address (if less than three years)
Home Phone *
Cell Phone
Work Phone
If necessary,may we call you at work? 123
May we send you text notifications? 123
Email Address
Date of Birth *
Social Security Number * Occupation *
Employer * Number of years Employed *
Spouse’s Information
First Name Date of Birth Social Security Number Occupation Home Phone If necessary,may we call you at work? 123
Last Name Relationship To Patient Employer Number of Years Employed Work Phone Cell Phone
Comments
Emergency contact
Name
Phone Number
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
First and Last Name Social Security Number Employer
Relationship to Patient Date of Birth Insurance Company
Group Number Phone Number Street Address
Zip/Postal Code Policy Holder's ID #
Second policy holder
Please complete the fields below if you have dual coverage.
First and Last Name Social Security Number Employer Group Number
Relationship to Patient Date of Birth Insurance Company Local Number
Phone Number Street Address
Authorization to Share Information
Please list any person(s) with whom we can discuss treatment and financials with (name, phone number and relationship)
orthodontic history
Please answer all questions for the patient if they are a minor, or for yourself if you are the patient.
What concerns you most about your teeth? *
Is this your first orthodontic evaluation? *
Has anyone in the family received orthodontic treatment by another orthodontist?
How did they feel about the results?
Names of any family members we have treated?
What is your attitude toward receiving orthodontic treatment? *
Dental history
Dentist * Street Address
Date of Last Visit
Do you have any of the following habits?
Thumb/Finger suckingTongue thrustSpeech ProblemsNail bitingMouth breathingLip sucking/biting
How many times a day do you brush your teeth?
How often do you floss your teeth?
Is any part of your mouth sensitive to pressure or temperature?
Do your gumm bleed when you brush?
Have you ever...
A bad experience in dental office ?
If so, pleasr describe:
Injuries to your face,mouth,teeth or chin ?
Chipped or lost any teeth unnaturally ?
Had your tonsils or adenoids removed, and at what age?
Have you ever had any of the following:
Wisdom teeth extractedOther teeth extractedPeriodontal (gum) treatmentYour bite adjustedSoreness of teeth or jaws when you awake in the morningClicking or propping of your jaw"Tension" headachesClenching your teeth during the dayGrinding your teeth at nightDificulty opening/closing/chewingChronic ringing in your earsTMJ Problems
Please comment on anything above you checked or anything else we should be made aware of?
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.
Physician Street Address
Date of Last Visit *
Weight
Please check any of the following which apply to you, and add any relevant comments.
Are you taking any medication?
Are you allergic to any medication?
Are you allergic to any metal?
Are you allergic to any latex?
Have you ever had a major illness?
Have you had any major operation?
Have you ever been involved in a serious accident?
Do you currently, have you ever taken any Bisphosphonate medications?(Acetonel/Risedronate,Aredia/Pamidronate,Didronel/Etidronate,Fosamax/Alendronate,Skelid/Tilndronate, Zoledronic Acid)
Are you Pregnant?
Do you smoke or use chewing tobacco?
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
Please comment on anything above you checked or any other medical considerations we should be informed of.
Parent/Guardian Signature(to be signed at first appointment) Witness Signature
Date Date
I understand that where appropriate, credit bureau reports may be obtained.
I give my permission for my x-rays, models and photographs to be used by Molen Orthodontics for the purposes of education,lectures,training and promotion.
