Download Because a beautiful smile makes a difference

About You
Orthodontic Insurance
Today’s Date____/____/____
Primary
Name:_____________________________________________________
Last
First
Mi
Mr Mrs Ms Dr
I prefer to be called:___________________________  Male  Female
Birthdate:_____/_____/_____ SS#:______________________________
HomeAddress:______________________________________________
__________________________________________________________
City
Do you
Rent
State
Own
Zip
How long at this address?_____________
 Single  Married  Divorced  Widowed  Separated
Hm #: (____)______________ Cell/ Other #: (____)________________
Wk #: (____)______________ Ext: _______
Orthodontic Coverage? Yes No
Insurance Co. Address:_______________________________________
__________________________________________________________
City
State
Zip
Insurance Co. Phone #: (____)__________________________________
Group # (Plan, Local, or Policy): _______________________________
Insured’s Name:______________________ Relation:_______________
Insured’s Birthdate:____/____/____ Insured’s ID #:________________
Insured’s Employer:_________________________________________
Employer’s address:_________________________________________
E-mail address:______________________________________________
Employer:__________________________________________________
__________________________________________________________
City
Employer’s Address:_________________________________________
__________________________________________________________
City
Dental Coverage? Yes No
Insurance Co. Name:_________________________________________
State
Zip
How Long there?___________ Occupation:_______________________
Where & when are the best times to reach you?____________________
Whom may we Thank for referring you?__________________________
State
Zip
Secondary
Orthodontic Coverage? Yes No
Dental Coverage? Yes No
Insurance Co. Name:_________________________________________
Insurance Co. Address:_______________________________________
__________________________________________________________
City
State
Zip
Other Family members seen by us:______________________________
Insurance Co. Phone #: (____)__________________________________
Previous/ Present Dentist:_____________________________________
Group # (Plan, Local, or Policy): _______________________________
(Please Circle)
Insured’s Name:________________________ Relation:_____________
Person Responsible for Account:________________________________
Insured’s Birthdate:____/____/____ Insured’s ID #:________________
Insured’s Employer:__________________________________________
Employer’s address:__________________________________________
__________________________________________________________
Spouse Information
City
State
Zip
His/ Her Name:_____________________________________________
I authorize the release of any information including the diagnosis and
Employer:_________________________________________________
records of any treatment or examination rendered to myself, and I am
Cell/ Other #:____________________ Wk #:_____________________
responsible for any costs associated with this. I authorize Dr. Wenderoth
SS #:_____________________________ Birthdate:_____/_____/_____
to obtain a credit report if indicated or warranted. I also consent to the
use of any photographs and x-rays by the doctor in scientific papers,
Relative or Friend not living with you (for emergency purposes only):
demonstrations, office marketing, office display and website display.
His/ Her Name:_____________________ Relation:________________
________________________________________________________
Wk #: (_____)________________ Hm #: (_____)__________________
Patient Signature
“Because a beautiful smile makes a difference”
619 South East Main Street x Simpsonville, South Carolina 29681 x (864) 967-9700 x Fax (864) 967-9750
www.drwenderoth.com
Date
MEDICAL HISTORY
Phone #: (___)___________________ Date of last visit:_____________
DENTAL HISTORY
What are the main concerns that you would like orthodontics to
accomplish?__________________________________________
____________________________________________________
Have you ever had or been evaluated for orthodontic treatment?
Good Fair Poor
Yes No
Yes No
Do you have a personal physician?
Physician’s Name:___________________________________________
Your current physical health is:
Are you currently under the care of a physician?
Yes No
Please explain:______________________________________________
Have you ever had a serious/ difficult problem associated with any
Yes No
previous dental work?
Do you smoke or use tobacco in any other form?
Yes No
Do you now or have you ever experienced pain/ discomfort in your jaw
Have you had any metal rods, pins or implants?
Yes No
joint? (TMJ/ TMD)?
Are you taking any prescription drugs?
Yes No
Your current dental health is:
Yes No
Good Fair Poor
Yes No
Please list each one and give reason:_____________________________
Do you still have wisdom teeth?
__________________________________________________________
Have you ever had an injury to your:
Have you ever taken Phen-Fen?
Do you have any speech problems?______________________________
Yes No
Also known as Redux or Pondimin.
If so, when?________________________________________________
For Women: Are you taking birth control pills?
Are you pregnant? Yes No
Are you nursing?
Yes No
Week #:___________
Yes No
Mouth Teeth Chin (Please Circle)
Yes No
Do you generally breathe through your mouth?
If yes, please circle: While Awake?
While Asleep?
Do you have any missing or extra permanent teeth?
Yes No
Are you happy with the way your smile looks?
Yes No
If not, what would you change?_________________________________
Have you ever had any of the following diseases or medical problems?
__________________________________________________________
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
__________________________________________________________
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Abnormal Bleeding/ Hemophilia
AIDS
Alcohol/ Drug Abuse
Anemia
Arthritis
Artificial Bones/Joints/Valves
Asthma
Blood Transfusion
Cancer/ Chemotherapy
Colitis
Congenital Heart Defect
Diabetes
Difficulty Breathing
Emphysema
Epilepsy
Fainting Spells
Frequent Headaches
Glaucoma
Hay Fever
Heart Attack/ Surgery
Heart Murmur
Hepatitis
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Herpes/ Fever Blisters
High Blood Pressure
HIV
Hospitalized for any reason
Kidney Problems
Liver Disease
Low Blood Pressure
Lupus
Mitral Valve Prolapse
Pacemaker
Psychiatric Problems
Radiation Treatment
Rheumatic Fever
Seizures
Shingles
Sickle Cell Disease
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis(TB)
Ulcers
Venereal Disease
Please list any serious medical condition(s) that you have ever
I understand that the information I have given is correct to the best of my
knowledge, that it will be held in the strictest confidence and that it is
my responsibility to inform this office of any changes in my medical
status. I authorize the dental staff to perform the necessary dental/
orthodontic services I may need.
__________________________________________________________
Patient Signature
Date
Our office is HIPAA compliant and is committed to meeting and
had:_______________________________________________________
exceeding the standards of infection control mandated by OSHA, the
__________________________________________________________
CDC and the ADA.
Are you allergic to any of the following?
Y N Aspirin
Y N Erythromycin
Y N Penicillin
Y N Codeine
Y N Latex
Y N Tetracycline
Y N Dental Anesthetics
Y N Jewelry/ Metals
Please list any other drugs/materials that you are allergic to:__________
__________________________________________________________
OFFICE USE ONLY
OFFICE USE ONLY
Verified Information:____________
Patient ID:____________
Date:____________
Patient Model Box:___________
“Because a beautiful smile makes a difference”
619 South East Main Street x Simpsonville, South Carolina 29681 x (864) 967-9700 x Fax (864) 967-9750
www.drwenderoth.com