Dental Forms

  • PATIENT

  • CLOSEST RELATIVE

  • DENTIST

  • PHYSICIAN

  • Other physicians/health care providers being seen now:

  • GENERAL INFORMATION

  • FINANCIAL RESPONSIBILITY

  • DENTAL INSURANCE

  • MEDICAL INSURANCE

  • Your answers are for office records only, and are confidential. A thorough medial history is essential to a complete orthodontic evaluation. For the following questions mark yes, no, or don't know/understand (dk/u).

  • MEDICAL HISTORY

  • DENTAL HISTORY

  • Have you had allergies or reactions to any of the following:

  • PATIENT HEALTH INFORMATION

  • MedicationTaken for 
    Add a row
  • FAMILY MEDICAL HISTORY

  • Have your parents or siblings ever had any of the following health problems? If so, please explain.

  • RELEASE AND WAIVER

  • I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.

  • I have read the above questions and understand them. 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. I will notify my orthodontist of any changes in my medical or dental health.

  • MEDICAL HISTORY UPDATES OR CHANGES

  • Patient

  • PARENT/GUARDIAN

  • DENTIST

  • GENERAL INFORMATION

  • FINANCIAL RESPONSIBILITY

  • DENTAL INSURANCE

  • MEDICAL INSURANCE

  • PHYSICIAN

  • Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, please mark yes, no, or don’t know/understand (dk/u).

  • MEDICAL HISTORY

  • DENTAL HISTORY

  • PATIENT HEALTH INFORMATION

  • MedicationTaken for 
    Add a row
  • FAMILY MEDICAL HISTORY

  • Have the parents or siblings ever had any of the following health problems? If so, please explain.

  • RELEASE AND WAIVER

  • I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company.

  • I have read the above questions and understand them. 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. I will notify my orthodontist of any changes in my child’s medical or dental health.

  • MEDICAL HISTORY UPDATES

  • CONFIDENTIAL INFORMATION QUESTIONNAIRE

  • Patient's Legal Name

  • Patient's Address

  • Work Address

  • Spouse's Name

  • Spouse's work address

  • EMERGENCY CONTACT INFORMATION

  • Person we may contact in case of an emergency (other than your family home)

  • REQUEST FOR CONFIDENTIAL COMMUNICATION

  • As my dental care provider, you may do the following with my permission:

  • INSURANCE AND FINANCIAL INFORMATION

  • CONFIRMATIONS

  • ASSIGNMENT & RELEASE

  • I hereby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due and authorize the dentists to release any information for this claim. I authorize that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by this dental office, I am obligated to pay said office in accordance with its credit terms and policy.

  • I consent to making of videotapes, photographs, and x-rays before, during, and after treatment, and to use the same by the doctor in scientific papers, demonstrations and/or presentations.

  • I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.