Download Patient Information Name of School Person responsible for Account

Patient Information
Date__________
LOCATION______________________
General Dentist _________________________
Patient’s Name______________________________________________________________________________
Last
First
Middle
Address____________________________________________________________________________________
Street
City
State
Zip
Home Phone_________________ Pt’s Work Phone ___________________ Cell Phone____________________
Birth Date ___\___\___ Parents/Guardians _____________________ ______________________ ___________
Mother
Father
Marital Status
Name of School ____________________________
Person responsible for Account - complete any information that is not the same as above or below
Name______________________________________________ Social Security #_______________________
Last
First
Middle
Address_________________________________________________________________________________
Street
City
State
Zip
Relationship to Patient______________________ Home # _________________ Cell #__________________
Employer_________________________ Occupation ____________________ Work #__________________
Email address_____________________________
The below policy holder's signature authorizes the office of Alpine and Rafetto Orthodontics to affix my name
to any and all claims or documents related to any and all orthodontic benefits due me and my dependents
through my employment. I authorize payment of orthodontic benefits, otherwise payable to me, directly to the
office of Alpine & Rafetto Orthodontics.
Dental / Orthodontic Insurance Information (DENTAL ONLY)
1. Policy Holder's Name__________________________Signature________________________________
Policy Holder’s Address________________________________________________________________
Employer______________________________________ Occupation____________________________
Relationship to Patient_____________________ SSN _________________ Birth Date _____\_____\____
Home #__________________ Work # ____________________ Cell #__________________________
ID number on card______________________________ Account # _____________________________
Name of Insurance Company ___________________________________________________________
Telephone Number of Insurance Company _________________________________________________
This BOX for office use only
Benefits:
Employee:
Covered YES NO
Spouse:
Covered YES NO
Age:
Ded:
Date__________Initial___________
2. Policy Holder’s Name _________________________ Signature _______________________________
Policy Holder’s Address _______________________________________________________________
Employer ____________________________________Occupation______________________________
Relationship to Patient___________________ SSN___________________ Birth Date _____\_____\____
Home #_____________________ Work #____________________ Cell #________________________
ID number on card_____________________________ Account #_______________________________
Name of Insurance Company____________________________________________________________
Telephone Number of Insurance Company_________________________________________________
This BOX for office use only
Benefits:
Employee:
Covered YES NO
Spouse:
Covered YES NO
Age:
Ded:
Date__________Initial___________
Who may we thank for referring you to our office? _____________________________________
List family members who have completed treatment or are currently being treated at our office:
________________________________________________________________________________
Concerns that you would like orthodontist to addressed:___________________________________
________________________________________________________________________________
Patient’s Health Information
Patient’s Physician_____________________________________ Phone # ___________________
List medications currently taking: ____________________________________________________
Are there any medical conditions that we should know about? ______________________________
________________________________________________________________________________
Have you ever had any of the following diseases, medical problems or allergies? (Circle Y or N)
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
Heart Murmur
Y N Psychiatric / Learning / Coordination problems
Rheumatic Fever
Y N Epilepsy / Seizures / Fainting Spells
Heart Surgery
Y N Diabetes / Tuberculosis (TB)
Pacemaker
Y N HIV & AIDS
Mitral Valve Prolapsed
Y N Hemophilia / Abnormal bleeding
Kidney problems
Y N Cancer / Chemotherapy / Radiation treatment
Asthma / Arthritis
Y N Artificial bones / Joints
Hepatitis
Y N Sinus / Breathing problems
Aspirin / Codeine
Y N Adenoids / Tonsils removed
Dental Anesthetics
Y N Latex / Rubber Gloves
Penicillin / Tetracycline / Erythromycin / Sulfa Meds
Are you aware of any other allergies? ______________________________________________
________________________________________________________________________________
Female teens: Please indicated month and year menses started ______________________________
Have you ever experienced pain, clicking, popping noises in your jaw joint? __________________
Have you ever had an injury to your mouth, teeth or chin? _________________________________
GOOD
FAIR
POOR
Would you say your overall dental health is:
I certify that I have read and understand the above questions. To the best of my knowledge, the
above questions have been completely and accurately answered. A photocopy of this document may
act as an original.
_______________________________________
Signature of Responsible Party
______________________
Date
Information Updates ____________________________
Initials
Date
Information Updates ____________________________
Initials
Date
6/13