Online Forms

Patient's First Name

Patient's Last Name

Nickname

Patient's Address

City

State

Zip

Gender

Home Phone

Date of birth

Age

Race

Cell Phone

School/Employer

Grade/position

Work phone

How did you hear about our office

Family members treated in our office

Reason for Consultation

Previous Dentist

Date of last cleaning

Has the patient been examined by an orthodontist before?

Yes No

Specify if other

Guardian's First Name

Guardian's Last Name

Guardian's Home Phone

Guardian's Address

Guardian's City

Guardian's State

Guardian's Zip

Guardian's Employer

Guardian's Work Phone

Date of birth

Social Security Number

Guardian's Cell Phone

Guardian's E-Mail

INSURANCE (IF APPLICABLE):

Company Name

Phone

Subscriber/Member ID

GUARDIAN #2 / INSURANCE INFORMATION

Is there a second guardian and / or additional insurance to add?

Yes No

INSURANCE (IF APPLICABLE):

Does the patient tend to be a mouthbreather?

Yes No

Does the patient snore at night?

Yes No

Does the patient seem rested in the morning?

Yes No

Is the patient often sleepy during the day?

Yes No

Has the patient seen an Ear, Nose & Throat Specialist?

Yes No

Is the patient using a sleep apnea device?

Yes No

Prescription Medications:

Allergies:

INSURANCE (IF APPLICABLE):

Acid Reflux

Yes No

ADHD/ADD

Yes No

AIDS/HIV

Yes No

Anemia

Yes No

Arthritis

Yes No

Asthma

Yes No

Autism

Yes No

Bone Disorders

Yes No

Cancer

Yes No

Cerebral Palsy

Yes No

Chest Pain

Yes No

Chronic Neck Pain

Yes No

Clicking of Jaw

Yes No

Jaw Pain

Yes No

Cold Sores/Herpes

Yes No

Diabetes

Yes No

Down Syndrome

Yes No

Endocrine Problems

Yes No

Emotional Disorders

Yes No

Epilepsy

Yes No

Headaches

Yes No

Heart Condition

Yes No

Hepatitis

Yes No

Ear Pain

Yes No

Immune Problems

Yes No

Kidney Problems

Yes No

Low Blood Pressure

Yes No

Muscular Disorders

Yes No

Nervous Disorders

Yes No

Organ Transplant

Yes No

Osteoporosis

Yes No

Painful Chewing

Yes No

Periodontal Problems

Yes No

Prolonged Bleeding

Yes No

Rheumatic Fever

Yes No

Scoliosis

Yes No

Seizures

Yes No

Sinus Problems

Yes No

TMJ Problems

Yes No

Tuberculosis

Yes No

__________________________________________________________________________________________________________________________

Do your gums bleed when you brush?

Yes No

Is the patient seeing any other dental specialists?

Yes No

Any dental restorations needing to be completed?

Yes No

Have there ever been any injuries to the face, mouth or chin?

Yes No

Have you ever lost or chipped any teeth?

Yes No

Do you have any pain or soreness around your face, neck or back?

Yes No

Is any part of your mouth sensitive to temperature or pressure?

Yes No

Is the patient currently pregnant?

Yes No

Have adenoids been removed?

Yes No

Have tonsils been removed?

Yes No

Currently taking any medications?

Yes No

Are antibiotics necessary prior to treatment?

Yes No

Allergies?

Yes No

Any diseases or problems not mentioned above?

Yes No

__________________________________________________________________________________________________________________________

Please check if the patient has, or ever had, any of the following habits?

Cheek, tongue or lip biting

Yes No

Clenching Teeth

Yes No

Fingernail Biting

Yes No

Grinding Teeth

Yes No

Tongue Sucking

Yes No

Thumb Sucking

Yes No

Tongue Thrusting

Yes No

I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status.
I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate orthodontic treatment on the above-named patient.
I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.

Typed Name/Signature

Relationship to Patient

Date:

If someone other than the parent(s) or guardian(s) listed above will be bringing the patient to appointments, please list here:

By submitting this form you agree to the above mentioned consent statement.

Patient Testimonials

Smile Stories

“Dr. Porter is so patient with me. I have long feared the dentist, and he takes his time to make sure that I am completely informed on the work needed and cost involved, comfortable and properly numb before he works, and even checks that I am well after the visit. His staff is pleasant and easy to work (which is so rare with most medical offices now). Can’t say enough good things about them!”

Logan C.

“Always professional and honest!”

Lisa K.

“I’ve been a patient since 2004. I know that my dentists are skilled professionals who always uphold the honor and integrity of their work. They are concerned about my wellbeing. I’m always glad to be one of their patients. Great office staff!!”

Elizabeth R.