Patient Forms

    Confidential Patient Information

    Confidential Responsible Party Information


    Mailing address (if different from residence)

    Previous Address (if less than three years)

    Spouse’s Information

    Emergency contact

    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

    orthodontic history

    Please answer all questions for the patient if they are a minor, or for yourself if you are the patient.

    Dental history

    Do you have any of the following habits?

    Thumb/Finger suckingTongue thrustSpeech ProblemsNail bitingMouth breathingLip sucking/biting

    Have you ever...

    A bad experience in dental office ?

    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

    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.

    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?

    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

    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.