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EMAIL [email protected] WEB vanlaeckenortho.com Completing this form in advance and bringing it with you to your appointment will save you a considerable amount of time. Thank you! PATIENT INFORMATION: DATE WORK PHONE PATIENT’S NAME EMAIL (FIRST, MIDDLE INITIAL, LAST, PREFERRED NAME) BIRTH DATE ADDRESS (STREET, CITY, STATE, ZIP CODE) AGE HOME PHONE DENTIST CELL PHONE GENDER MALE FEMALE WHO MAY WE THANK FOR REFERRING YOU TO OUR PRACTICE? OFFICE STAFF (NAME) DENTIST (NAME) FRIEND (NAME) SIGNAGE WEBSITE/ INTERNET INVISALIGN SCHOOL PROMOTION/ DIRECT MAILING RESPONSIBLE PARTY INFORMATION: SELF OR PARENT/GUARDIAN IF UNDER 18 SELF OR PARENT/GUARDIAN IF UNDER 18 ADDRESS ADDRESS HOME PHONE HOME PHONE CELL PHONE CELL PHONE WORK PHONE WORK PHONE EMAIL EMAIL BIRTH DATE BIRTH DATE RELATIONSHIP TO PATIENT RELATIONSHIP TO PATIENT SOCIAL SECURITY NUMBER SOCIAL SECURITY NUMBER EMPLOYER EMPLOYER INSURANCE COMPANY INSURANCE COMPANY INSURANCE COMPANY ADDRESS INSURANCE COMPANY ADDRESS INSURANCE POLICY/GROUP NUMBER INSURANCE POLICY/GROUP NUMBER INSURANCE ID NUMBER INSURANCE ID NUMBER (FIRST, MIDDLE INITIAL, LAST) (STREET, CITY, STATE, ZIP CODE) (FIRST, MIDDLE INITIAL, LAST) (STREET, CITY, STATE, ZIP CODE) SPORTS TEAM/ SPONSORSHIP EMAIL [email protected] WEB vanlaeckenortho.com I agree that Ryan K. VanLaecken D.D.S., M.S., Rob S. VanLaecken, D.D.S., M.S. or Robert A. Arnold, D.D.S., M.S. may access any credit references and/or credit reports that they deem necessary. I understand that VanLaecken Orthodontics provides only an estimate of the amount that the insurance policy may pay, and I will be responsible for the portion of the fee that insurance does not cover. I hereby authorize release of information relating to this and future insurance claims (including the addition of insurance at a later date) to the above named orthodontists. Signature (Parent/Guardian signature if minor)Date For Office Use Only Conf. Date: Benefit Amt: Age Limit: Deductible: Pymt. Interval: M Q S A Benefit Remaining: % of fee charged: Auto/Non Auto: Other Staff: MEDICAL HISTORY: IS IT NECESSARY TO PRE-MEDICATE PATIENT BEFORE APPOINTMENT? YES NO IS THE PATIENT UNDER THE CARE OF A PHYSICIAN NOW? YES NO IF SO, WHAT CONDITION NAME OF PHYSICIAN MEDICAL HISTORY MEDICATIONS (PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING OR HAVE TAkEN IN THE LAST SIX MONTHS INCLUDING HEART OR BLOOD PRESSURE, CORTISONE, ANTICANCER, ANTIFUNGAL, ANTIBIOTIC, OSTEOPOROSIS/BONE LOSS TREATMENT OR MEDICATIONS) (LIST PAST AND CURRENT, INCLUDING HEART MURMUR, RHEUMATIC FEVER, MITRAL VALVE PROLAPSE SYNDROME, HYPERTENSION, HEMODIALYSIS, JOINT REPLACEMENT, HEMOPHILIA, ASTHMA, GLAUCOMA) VIRAL INFECTIONS HOSPITALIZATIONS (LIST PAST AND CURRENT INCLUDING HERPES SIMPLEX, MONONUCLEOSIS, SHINGLES, HEPATITIS, AIDS) DOES THE PATIENT USE TOBACCO PRODUCTS? (PLEASE LIST ALL) YES NO IF SO, LIST FREQUENCY OF USE AND APPROXIMATE QUANTITY OF USE RECENT INJECTIONS OTHER THAN DENTAL, TETANUS, ETC. (DATE) TRANSFUSIONS: (DATE) ARE THERE ANY OTHER CONDITIONS, SYNDROMES OR HEALTH ISSUES NOT LISTED? ALLERGIES TO DRUGS: (IE. PENICILLIN, LOCAL ANESTHETICS) DO YOU HAVE A FREQUENT “STUFFY NOSE”? YES NO ALLERGIES TO FOOD: DO YOU HAVE A FREQUENT SORE THROAT OR TONSILITIS? YES NO ALLERGIES TO SEASONAL THINGS: DO YOU HAVE DIFFICULTY CHEWING OR SWALLOWING? YES NO ALLERGIES TO OTHER THINGS: (IE. NICKEL, LATEX) HAVE YOU RECEIVED MEDICAL TREATMENT FROM AN ALLERGIST OR EAR, NOSE & THROAT SPECIALIST? YES DO YOU BREATHE THROUGH YOUR MOUTH? SELDOM SOMETIMES NO IF SO, WHEN? USUALLY IF SO, BY WHOM? DO YOU SNORE WHEN SLEEPING? YES NO DO YOU HAVE FREQUENT COLDS? YES NO NASAL SURGERY TONSILS REMOVED ADENOIDS REMOVED EMAIL [email protected] WEB vanlaeckenortho.com DENTAL AND TEMPOROMANDIBULAR JOINT HISTORY HAS THE PATIENT HAD ANY UNUSUAL DENTAL EXPERIENCES? YES NO YES NO IF YES, PLEASE SPECIFY: HAS THE PATIENT HAD ANY INJURIES TO THE MOUTH, TEETH OR JAW? IF YES, PLEASE SPECIFY: WERE THE PATIENT’S TEETH CLEANED AT THIS TIME? DATE OF LAST DENTAL VISIT: HAS THE PATIENT EVER RECEIVED A SEVERE BLOW TO THE TEETH OR JAW? YES NO HAS THE PATIENT HAD AN ORTHODONTIC CONSULT/TREATMENT? HAS ANYONE ELSE IN THE PATIENT’S FAMILY HAD ORTHODONTIC TREATMENT? YES NO IS THE PATIENT ADOPTED? WHO DOES THE PATIENT LOOK MOST LIKE? MOTHER FATHER YES NO YES NO YES NO DOES THE PATIENT HAVE: HEADACHES NECK PAIN JAW PAIN IF SO, WHICH SIDE HURTS? RIGHT EAR PAIN FACE PAIN OTHER EYE PAIN IF SO, HOW LONG HAVE THESE SYMPTOMS BEEN PRESENT? MONTHS YEARS BOTH LEFT DAYS IS THE PAIN: CONSTANT ACHING SHOOTING STABBING ELECTRICAL WORSE IN THE MORNING WORSE IN THE AFTERNOON DOES IT HURT TO CHEW? DOES IT HURT TO OPEN WIDE? OTHER DOES THE PATIENT’S JAW EVER MAKE: A POPPING NOISE DOES THE PATIENT EVER CLENCH OR GRIND HIS/HER TEETH? YES NO CLICKING IF SO, WHEN? GRINDING OTHER DURING THE DAY DURING THE NIGHT HAS THE PATIENT’S JAW EVER LOCKED UP OR SLIPPED OUT OF PLACE? YES DOES THE PATIENT HAVE PROBLEMS WITH HIS/HER: IS IT DIFFICULT OR PAINFUL TO SWALLOW? YES NO NO EARS HEARING ARE THE TEETH SORE OR SENSITIVE? DIZZINESS YES OTHER NO EMAIL [email protected] WEB vanlaeckenortho.com DENTAL AND TEMPOROMANDIBULAR JOINT HISTORY CONT’D DOES THE PATIENT EXHIBIT: THUMB OR FINGER SUCKING TONGUE THRUST (REVERSE SWALLOWING) LIP BITING NAIL BITING POOR SPEECH HABITS DOES THE PATIENT WANT HIS/HER TEETH STRAIGHTENED? YES NO WHAT IS THE PATIENT MOST CONCERNED ABOUT? BITE APPEARANCE OTHER FACIAL PROFILE PATIENT SURVEY FORM HELP US GET TO KNOW YOU BETTER! FILL OUT THE FOLLOWING SURVEY TO HELP US BETTER SERVE YOU. WHAT ARE YOUR FAVORITE ACTIVITIES/HOBBIES? DO YOU LIKE SPORTS? YES NO IF SO, WHAT IS YOUR FAVORITE TEAM? WHAT IS YOUR DREAM JOB? WHO IS YOUR FAVORITE SINGER OR BAND? WHAT IS YOUR FAVORITE TYPE OF MUSIC? WHAT IS YOUR FAVORITE TV SHOW OR MOVIE? WHAT IS YOUR FAVORITE FOOD OR RESTAURANT? DO YOU HAVE A PET? YES NO WHAT IS YOUR FAVORITE VACATION SPOT? WHAT IS YOUR PET’S NAME? WHAT COMMUNITY GROUPS/ACTIVITIES DO YOU PARTICIPATE IN? CONSENT OF PARENT OR LEGAL GUARDIAN TO INITIAL ORTHODONTIC EXAMINATION I (we) understand, that by signing this, I (we) are providing our consent to VanLaecken Orthodontics and its staff and personnel to conduct an Initial Orthodontic Examination for: (Print Patient’s FULL Name) SIGNATURE PLEASE PRINT NAME RELATIONSHIP TO PATIENT DATE SIGNATURE PLEASE PRINT NAME RELATIONSHIP TO PATIENT DATE