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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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