FormTest LP – No Money Down Form Request an Appointment Form <br /> Patient Information Date Patient's Full Name Nickname Date of Birth Sex MaleFemale Age How did you find us? Please SelectSearch EngineDoctor ReferralFriend Address Address line 2 City State / Province Zip / Postal Code Country Telephone # Cell Phone # Email Address Referred By Dentist Physician School School Address Father's / Husband's Full Name Employed By Business Address Cell phone # Father's S.S# Date of Birth Business Phone Mother's / Wife's Full Name Employed By Business Address Cell phone # Mother's S.S# Date of Birth Business Phone Is Patient Living With Both Parents? YesNo If Not, With Whome is Patient is Living? Do You hve Orthodontic Dental Insurance? YesNo Insurance Company (If Delta Dental INS, please provide Delta Dental of WHAT STATE) ID # Group# Insured Name and DOB Person Responsible for This Account FatherMotherGuardianOther Name of Responsible Person if not Parent Billing Address City State Zip Phone Brother's Age Sister's AGe Sports And Hobbies Musical Instrument Played Has patient ever had any previous orthodontic consultation or treatment? YesNo REMARKS HAS ANY OTHER FAMILY MEMBER RECEIVED ORTHODONTIC CARE? YesNo IF YES, WHO? Medical History Please check any of the following: AdenoidsAnemiaArthritisAsthmaPolioEmotional ProblemsEpilepsyBone DisordersDiabetesEndocrinePneumoniaPoor HealthProlonged BleedingRheumatic FeverTuberculosisFaintingDizzinessHepatitisHIV +/ AIDSHigh CholesterolNone of These Weight Height DOES PATIENT HAVE TENDENCY TO COLDS? YesNo SORE THROATS? YesNo EAR INFECTIONS? YesNo HAVE TONSILS OR ADENOIDS BEEN REMOVED? WHAT AGE? ANY BROKEN BONES? PLEASE LIST: DID THEY HEAL SATISFACTORILY? DOES PATIENT BLEED EASILY? HAVE HIGH FEVER WITH CHILDHOOD DISEASES? ANY PSYCHOLOGICAL COUNSELING? HAS THE PATIENT REACHED PUBERTY? YesNo GIRLS-HAS SHE STARTED MENSTRUATION? YesNo BOYS - HAS HIS VOICE CHANGED? YesNo OTHER ILLNESSES. CONDITIONS. ALLERGIES. ETC: DID PATIENT EVER HAVE AN ALLERGY TO ANY DRUG OR MEDICATION: YesNo IF YES. REMARKS: TO THE BEST Of YOUR KNOWLEDGE, IS THE PATIENT IN GOOD HEALTH? YesNo IF PATIENT IS UNDER THE CARE OF A PHYSICIAN FOR A SPECIFIC CONDITION OR IS TAKING ANY MEDICATIONS PLEASE EXPLAIN AND LIST. Dental History HAS THE PATIENT HAD ANY INJURIES TO THE FACE? MouthTeethFace HAS THE PATIENT EVER SUCKED A THUMB OR FINGERS? YesNo HAS THE PATIENT HAD ANY TEETH REMOVED AT ANY TIME BY A DENTIST? DOES THE PATIENT HAVE ANY SPEECH PROBLEMS? IS THE PATIENT A MOUTH-BREATHER? YesNo WHILE AWAKE? DOES FACE AND MOUTH RESEMBLE: MotherFatherNeither DO YOU MAKE REGULAR VISITS TO THE DENTIST? WHEN LAST? HOW OFTEN DOES PATIENT BRUSH HIS/HER TEETH? ANY PAIN IN OR NEAR THE EARS? LEFT RIGHT ANY CLICKING OR DISCOMFORT OF THE JAW JOINT NEAR EARS? RIGHT LEFT DOES PATIENT DESIRE TREATMENT? IN YOUR OWN WORDS WHAT WOULD YOU LIKE US TO ACCOMPLISH FOR YOUR CHILD? OTHER RELEVANT INFORMATION: Signature of Patient Date Acknowledgement of Receipt of Notice of Privacy Practice I have been informed of your Notice of Privacy of Practice containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practice from time to time and that I may contact this organization at any time at the above address to obtain a current copy of the Notice of Privacy Practices I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. Patient Name Signature Relationship to Patient Date
