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Please take a minute to print and fill out the patient information form before your first appointment:

Patient Form (Child & Adult) PDF | DOC

Patient forms are essential documents used in healthcare settings to gather important information about patients before they receive medical care. These forms typically include personal details such as name, date of birth, contact information, and emergency contacts. They also capture medical history, including past illnesses, surgeries, allergies, and current medications, which are crucial for accurate diagnosis and treatment. Additionally, patient forms often require information about insurance coverage and consent for treatment, ensuring that both the healthcare provider and the patient are clear on the terms of service and financial responsibilities. Completing these forms accurately and thoroughly is vital for providing effective care, as it allows healthcare professionals to tailor their approach to each patient’s unique needs. They also serve as a legal document that protects both the patient and the provider by documenting consent and acknowledging the terms of care. In many practices, these forms are increasingly being made available electronically, which streamlines the process and enhances accessibility. This digital shift not only simplifies the completion and submission process for patients but also improves the efficiency of healthcare operations by reducing paperwork and the potential for errors. Overall, patient forms are a critical component of the healthcare system, facilitating smooth interactions between patients and providers and contributing to the delivery of high-quality care.

PATIENT INFORMATION

Date

Patient’s name

Address

Phone

Date of birth

Social Security #

Patient General Dentist

Whom may we thank for referring you to our office?

RESPONSIBLE PARTY INFORMATION

Name

Address

Cell phone

Home phone

Social Security #

Birthdate

Relationship to Patient

Spouse's Name

Social Security #

Birthdate

Cell Phone

DENTAL INSURANCE INFORMATION

Insured's Name

Insured's Social Security #

Employer

Occupation

Insurance Company

Group No.

Local No.

Insurance Co. Address

Phone No.

Do you have dual coverage?
YesNo

Insured's Name

Insured's Social Security #

Employer

Occupation

Insurance Company

Group No.

Local No.

Insurance Co. Address

Phone No.

EMERGENCY INFORMATION

Name of nearest relative not living with you

Complete address

Phone

MEDICAL HISTORY

Physician

Date of Last Visit

Address

Phone

Please select Yes or No (If Yes, please fill in details)

Are you taking any medication?
YesNo

Are you allergic to any medication?
YesNo

Do you have a history of a major illness?
YesNo

Have you had any operations?
YesNo

Have you ever been involved in a serious accident?
YesNo

Have seen a physician in the last 12 months? Why?
YesNo

Select any of the medical conditions below that you have had or currently have.

Abnormal bleeding / HemophiliaAnemiaArthritisAsthma or Hay feverBone DisordersCongenital Heart DefectDiabetesDizzinessEpilepsyGastrointestinal DisordersHeart ProblemsHeart MurmurHepatitis/Liver problemsHerpesHigh Blood PressureHIV / AidsKidney problemsNervous DisordersPneumoniaProlonged BleedingRadiation/ChemotherapyRheumatic FeverTuberculosisTumor or Cancer

Are there any medical conditions we have not discussed that you feel we should be aware of?

DENTAL HISTORY

General Dentist

Date of last visit

What concerns you most about your teeth?

Are you presently in any dental pain?
YesNo

Have you ever experienced any unfavorable reaction to dentistry?
YesNo

Have you ever lost or chipped any teeth?
YesNo

Have there been any injuries to face, mouth, or teeth?
YesNo

Is any part of your mouth sensitive to temperature? Where?
YesNo

Is any part of your mouth sensitive to pressure? Where?
YesNo

Do your gums bleed when you brush?
YesNo

Do you have any type of thumb or tongue habit?
YesNo

Are you a mouth breather?
YesNo

Have you ever seen an orthodontist? If yes, who and when?
YesNo

Do your teeth or jaws ever feel uncomfortable when you wake up in the morning?
YesNo

Are you aware of your jaw clicking or popping?
YesNo

Are you aware of clenching your teeth during the day?
YesNo

Have you ever been told that you grind your teeth?
YesNo

Do you have “tension” headaches?
YesNo

Have you ever experienced chronic ringing in your ears?
YesNo

Female Patients only: Are you pregnant?
YesNo

I understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Transcend Orthodontics LLC to perform a complete orthodontic evaluation.

Signature:

Date: