Patient Forms

Please take a minute to print and fill out the patient information form before your first appointment:

Patient Information:

Bold fields are required.

Patient Type Date Patient Name First and Last Preferred Name / Nickname Date of Birth Gender Address Line 1 Address Line 2 City State/Province Zip Code Phone Number Email Address Preferred Contact Method

Responsible Party (Minors Only) Parent / Guardian Name First and Last Relationship to Patient Phone Number Email Address Marital Status Who Does The Child Live With?

General Information How Did You Hear About Us? What Do You Dislike About Your Smile? Hobbies / Interests School Name (Optional) Other Family Members Seen At Our Office

Dentist/Physician information Dentist Name First and Last Dental Office Location Dentist Phone Number Date Of Last Cleaning Currently Under Physician Care? If Yes, Explain

Insurance Information Do You Have Dental Insurance?

Primary Insurance Subscriber Name First and Last Relationship To Patient Employer Subscriber ID Number Subscriber Date of Birth Insurance Company Group Number Address Line 1 Address Line 2 City State/Province Zip Code

Secondary Insurance Subscriber Name First and Last Relationship To Patient Employer Subscriber ID Number Subscriber Date of Birth Insurance Company Group Number Address Line 1 Address Line 2 City State/Province Zip Code

Patient’s Dental/Medical History

Orthodontic Concerns?

Family Members With Similar Dental Problems Do You Experience Jaw Pain Or Clicking? If Yes, Which Side? Do You Grind Or Clench Your Teeth? Do You Have Difficulty Chewing? Have You Experienced An Injury To Your Face Or Teeth? If Yes, Explain Have You Been Told You Have A Tongue Thrust Swallowing Pattern? Have You Had A Previous Orthodontic Consultation? If yes, When? Have You Previously Received Orthodontic Treatment? If Yes, Explain

Child Only Questions Interest In Orthodontic Treatment Has The Patient Reached Puberty? If yes, Approximate Date

General Health Overall Health Do You Smoke? Is There Anything In Your Medical History We Should Be Aware Of? If Yes, Explain Current Medications

Allergies?

Medical Conditions?

Acknowledgement

I certify that the information provided is accurate and complete to the best of my knowledge.

I understand that I am responsible for informing the office of any changes to my medical history.

12151 W Parmer Ln
Unit A, Suite 101
Cedar Park, TX 78613

(512) 260-0084

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