Download Patient Information - Oliver Orthodontics

Welcome To Our Office
The benefits of a happy, healthy smile are
immeasurable! Our goal is to help you reach and
maintain maximum oral health. Please fill out this
form completely. The better we communicate, the
better we can care for you.
Patient Information
Patient’s Name____________________________
Address__________________________________
City_________________State_____Zip________
Birthdate_____________SS#_________________
Home#_____________Cell #_________________
School____________________________________
Hobbies___________________________________
Email Address_____________________________
Dental Insurance Information
Whom may we thank for referring you to
our office? ________________________
Responsible Party Information
Name_____________________________________
Address_________________________________
City__________________State______Zip_______
Home#______________Work#________________
Cell#_____________________________________
Birthdate_______________SS#________________
Relationship to Patient_______________________
Employer_______________Years Employed_____
Occupation________________________________
Email Address_____________________________
Spouse’s Name____________________________
Birthdate________________SS#_______________
Work#__________________Cell#______________
Employer_______________Years Employed_____
Occupation________________________________
Other family members seen by Dr Oliver_______
__________________________________________
Subscriber Name____________________________
Birthdate_______________SS#________________
Relationship to patient_______________________
Insurance Co.______________________________
Insurance Phone #___________________________
Do you have secondary coverage? Yes No
If yes, please list coverage____________________
_________________________________________
Emergency Information
Name of nearest relative not living with you
__________________________________________
Address___________________________________
City_________________State_____Zip_________
Home#______________Work#________________
Dr. Brian Oliver
Orthodontics for Children & Adults
5901 Grelot Road Building E
Mobile, AL 36609
Tel 251-639-0801
Fax 251-461-0794
HEALTH HISTORY
Medical History
Our office is committed to meeting or exceeding the
standards of infection control mandated by OSHA,
the CDC, and the ADA.
Your Dentist
Physician’s Name _____________________________
Date of last Visit ______________________________
Current Medications____________________________
_____________________________________________
Allergies (including drugs, nickel, latex, etc.)________________
Previous/Present dentist______________________
_________________________________________
Date of last visit____________________________
______________________________________________________
Have you ever had surgery or been hospitalized and why? _______
______________________________________________________
Your current physical health is Good Fair Poor
Does patient have a history of any of the following?
Dental History
Why have you come to the orthodontist today?____
__________________________________________
__________________________________________
Are you currently in pain?
Yes No
Your current dental health is Good Fair Poor
Please check any of the following conditions that
apply to patient:
Y N Bleeding Gums
Y N Grinding Teeth
Y N Jaw/Joint Pain
Y N Periodontal/Gum Treatment
Y N Clicking/Popping Jaws
Y N Cleft Palate
Y N Tooth Sensitivity
Y N Headaches
Y N Anemia
Y N Arthritis, rheumatism
Y N Asthma
Y N Blood Disease
Y N Chemical Dependency
Y N Chemotherapy/Cancer
Y N Cough/Persistent
Y N Diabetes
Y N Epilepsy/fainting spells
Y N Heart Problems/Murmur
Y N Hepatitis
Y N High Blood Pressure
Y N Rheumatic/Scarlet Fever
Y N Kidney Disease
Y N Liver Disease
Y N Mitral Valve Prolapse
Y N Radiation Therapy
Y N Shortness of Breath
Y N Stroke/Heart Attack
Y N Thyroid Problems
Y N Tobacco Habit
Y N Tuberculosis
Y N Ulcer
Y N Venereal Disease
Y N HIV+/Aids
Describe Heart Problems_____________________
_________________________________________
Does patient require pre-medication_____________
AUTHORIZATION
I understand the above questions and have provided accurate answers to the
best of my knowledge. It is my responsibility to inform this office of any
changes in the patient’s medical status. I understand that providing
incorrect information can be dangerous to the health of those individuals
treating the patient. I understand that once a diagnosis and treatment plan
has been developed, the fees and methods of payment will be discussed
with me and a financial agreement will be established. I understand that,
when appropriate, credit reports may be obtained. I also authorize the
release of any information regarding diagnosis and the records of any
treatment or examination rendered to the patient during orthodontic care to
third party payers and/or health practitioners. I understand that my dental
insurance may pay less than the actual amount owed for services. I agree
to be responsible for payments of all services rendered on my or patient’s
behalf.
Name (please print)__________________________
Signature__________________________________
Relationship to patient____________Date________