Download Today`s date: _________ ACQUAINTANCE FORM Patients

Today’s date: ____________
ACQUAINTANCE FORM
Patients Name____________________________________ Nickname ____________________________Age_____ Sex:
M
F
Date of Birth _________ Home Number __________________ E-mail Address___________________________________________
Address___________________________________________________________________________________________________
Whom may we thank for referring you? ______________________________ Do you have dental insurance? Yes____ No _____
Insurance Company_____________________________ Insurance ID#_________________ Policy Holder_____________________
Secondary Insurance Co__________________________ Insurance ID#_________________ Policy Holder____________________
Preferred method to confirm appointments:
E-mail
Text message
Phone call
For minor child:
Mother’s Name ______________________________ Mothers Employer_________________________ Date of Birth ____________
Work Phone____________________ Mobile__________________ Social Security Number_________________________________
Father’s Name ______________________________ Fathers Employer______________________ Date of Birth ________________
Work Phone_____________________ Mobile _____________________ Social Security Number____________________________
Patient Lives With______________________________ School_________________________________ Grade______
HEALTH HISTORY
YES NO
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Is the patient in good health? If no please explain: ___________________________________________________________
Does the patient have any history of major illness? If yes please explain: _________________________________________
Is the patient currently taking any medications? Please give medication and reason: ________________________________
Is the patient allergic to anything? _______________________________________________________________________
Please check if the patient has been treated for any of the following:
___ Heart disease
___ Anemia
___ Cerebral palsy
___ Learning Disability
___ Liver disease
___ Rheumatic fever
___ Cleft lip/palate
___ Speech/hearing
___ Kidney disease
___ Seizures
___ AIDS/HIV
___ Herpes
___ Bleeding/transfusion
___ Diabetes
___ Depression
___ Tuberculosis
___ Asthma
___ Hepatitis
___ ADD/ADHD
___ Other Problems
Elaborate:________________________________________________________________________________________________________________
DENTAL HISTORY
Patient’s Dentist__________________________________ Phone_________________ Date of last exam _____________
Reason for orthodontic consultation? ____________________________________________________________________
YES NO
___ ___ Has an orthodontist been consulted previously? Name _____________________________________________
___ ___ Have you been informed of any missing or extra permanent teeth?
___ ___ Have there been injuries to the face, mouth, or teeth?
___ ___ Does the patient have pain with chewing, yawning or wide opening?
___ ___ Does the patient’s jaw make noise and is pain associated with the sounds?
___ ___ Has either parent had orthodontic treatment?
Patient/Parent signature ___________________________________________