Patient Forms

Patient Information

Patient's Name *

First

Last

Nickname

Layout

Birthdate

Gender *

M
F
Non-binary

Marital Status *

Street Address *

City *

State *

Zip *

Best Phone Number *

Email Address *

Layout

Employer or School *

Employment Status *

General Dentist *

Date of Last Visit

How did you hear of our office? *

List any Family Member Seen by Us

Responsible Party

Is the patient 18 years old or older? *

Responsible Party’s Name *

First

Last

Layout

Relationship to Patient *

Birthdate

Street Address (if different from patient’s)

City

State

Zip

Best Phone Number *

Email Address *

Marital Status

Employer

Occupation

Insurance Information

Do you have DENTAL insurance? *

Does our office already have your insurance information? *

Insurance Company Name *

Phone *

Insurance Co. Address *

City *

State *

Zip *

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Policy Holder (subscriber) Name *

Birthdate

Employer

Policy Holder’s Address (if different from patient’s)

City

State

Zip

ID/policy # *

Group # *

Do you have dual coverage? *

Secondary Insurance Company Name *

Phone *

Insurance Co. Address *

City *

State *

Zip *

Policy Holder (subscriber) Name *

Birthdate *

Employer

Policy Holder’s Address (if different from patient’s)

City

State

Zip

ID/policy # *

Group # *

Medical/Dental History

Physician's Name

Phone

Are you currently under any medical treatment? *

Please explain *

History of surgeries or hospitalizations? *

List *

Are you currently taking any medication? *

List *

Have you ever taken, or were given, Fosamax or other Bisphosphonates? *

Has there been any history of:

Asthma
Tuberculosis (TB)
Diabetes
HIV / AIDs
Cancer
Kidney disease
Liver condition
Epilepsy
Rheumatic fever
Other major illnesses?

If other, which? *

Do you bleed or bruise easily? *

Do you have a tendency to faint or become dizzy? *

Do you have any allergies? *

Please list all allergies: *

Do you have a heart condition? *

Please explain *

Do you pre-medicate before dental appointments? *

Do you have pain, clicking, and/or popping noises in the jaw? *

Are you aware of either clenching or grinding of teeth? *

Do you have frequent headaches? *

How often? *

Do you have ear problems? (aches, ringing, dizziness, fullness) *

Do you have difficulty breathing through the nose? *

Have you had your tonsils and/or adenoids removed? *

Do you have sleep apnea? *

Do you have speech problems, or are you in speech therapy? *

Do you smoke, vape or chew tobacco? *

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

Please explain *

Have you had any permanent teeth extracted? *

Have you been informed of missing or extra permanent teeth? *

For women: are you currently pregnant or nursing?

In case of emergency, who should we contact: *

Relation to patient: *

Phone Number: *

What are your main orthodontic concerns? *

Have you ever had an orthodontic evaluation or treatment before? *

How would you measure your interest in orthodontic treatment? *

Very interested
Mildly interested
Only want to hear about options

What kind of orthodontic treatment are you seeking? *

Braces
Invisalign
Surgery
Not sure

Is there any other personal or medical consideration you would like us to be aware of while providing you with our services?

At Hillsdale Orthodontics, we use custom-made braces and Invisalign aligners that require prior preparation by the laboratory. If the patient or the financially responsible party consents to the start of treatment, verbally or in written form, and does not follow through with treatment, the responsible party agrees to pay for the incurred laboratory fees.

Responsible party signature *

Date *

Patient Forms

Patient Information

Responsible Party

Insurance Information

Medical/Dental History

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