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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 ___ ___ ___ ___ ___ ___ ___ ___ 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 ___________________________________________