Patient Login
Call or Text: 248.588.2020
First Name*
Middle Name
Last Name*
Preferred Name
Gender* MaleFemale
Date of birth*
Best Phone Number* Phone Type—Please choose an option—CellHomeWork
Alternate Phone Number
Email Address*
Marital Status
Spouse’s Name (if applicable)
Home Address
Street*
City*
State*
Zip/Postal Code*
Family Dentist (if you have one):
How did you hear about our office (friend, cousin, Google search, dentist, etc)*:
Please list any family members seen by us:
yes
Relationship to Patient*
Gender MaleFemale
Birth Date
Check if Address Same as Above Address
Best Phone Number —Please choose an option—CellHomeWork
Best Phone Number* —Please choose an option—CellHomeWork
Check if yes have insurance
Primary Policy Holder's First Name*
Primary Policy Holder's Last Name*
Insurance Company*
Insurance Company Phone Number
Subscriber's Birth Date
Subscriber's Employer*
Subscriber/Member ID Number
Subscriber's Social Security Number (U.S. only)
Secondary Policy Holder's First Name*
Secondary Policy Holder's Last Name*
Now or in the past, has the patient had: Attention Deficit DisorderAllergy to LatexArthritisBehavioral problemsBirth Defects or Hereditary ProblemsBone or Joint DisorderDiabetesEpilepsy or ConvulsionsFainting or DizzinessFrequent Headaches or MigrainesGagging or nausea problemsGrowth or Endocrine ConditionHearing DisorderHeart DisorderPsychiatric Treatment or Psychological Disorder
Patient is pregnant YesNo
Any Medications patient is currently taking:
Have tonsils or adenoids been removed: YesNo
if so what age:
Any other medical conditions we should be aware of:
Any known Allergies:
Have you been examined by an orthodontist in the last 2 years? YesNo
If so, Doctor & Date
Have you ever had orthodontic treatment before? YesNo
if so explain:
Have there ever been any injuries to the face, mouth or teeth? YesNo
If so, please tell us briefly what happened
Do you regularly snore? YesNo
Do you currently have any dental pain? YesNo
Has there been a regular thumb or finger sucking habit AFTER the age of 5? YesNo
Until what age?:
Are you aware of any regular clenching or grinding of your teeth during the day or while sleeping? YesNo
Has a dentist or hygienist ever told you that you currently have or have had periodontal disease? YesNo
Please briefly explain your main concern for scheduling this consultation:
I have read and understand the above questions. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status, I will so inform this practice.
Patient/Legal Guardian Electronic Signature:
Please enter your full name*
Today's date*
Δ
The first step toward achieving a beautiful, healthy Smile For Life! is to schedule an appointment
Schedule an Appointment
