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Patient Information (Adult)

Gender*
Date of Birth*
Whom may we thank for referring you?
Marital Status*

Spouse Information

Spouse's Date of Birth*

Patient Information (Child)

Gender*
Date of Birth*
Names please.
Parent, Step-Parent, Grand Parent, etc.
Names please.
Names Of Siblings and Birthdates
Name
Birthdate
 
Whom my we thank for referring you?

Responsible Party

Who will be the primary responsible party for the patient’s orthodontic treatment?*
Marital Status of Responsible Party?*

Mother's Information

Mother's Relationship*
Mother's Date of Birth*

Father's Information

Father's Relationship*
Father's Date of Birth*

Guardian's Information

Guardian's Gender*

Male

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Relationship to Patient*
Guardian's Date of Birth*

Female

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Relationship to Patient*
Guardian's Date of Birth*

Primary Insurance Information

Insurance?
Subscriber's Date of Birth*
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If using a mobile phone or tablet to complete this form, you can use this button to snap a photo of the card. Otherwise, you may upload a photo of it here.
Accepted file types: jpg, gif, png, Max. file size: 2 GB.

Secondary Insurance Information

Secondary Insurance?
Subscriber's Date of Birth*

Emergency Contact Information

Medical History

We are passionate about our mission to give everyone a great smile. Please help us help you and your child by letting us know of any delayed development, social disabilities, ADD or ADHD, Bipolar, Autism, etc.
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Is the patient under medical treatment now?*
Has the patient been hospitalized for any surgical operations or serious illness in the past five years?*
Is the patient taking medication(s) including non-prescription medicine?*
Does the patient use tobacco?*
Is the patient aware of being allergic to any medications or substance including metals?*
Has the patient ever taken Bisphosphonates (EX: Fosamax) for Osteoporosis?*
Has the patient reached puberty?*
Has menstruation begun?*
MM slash DD slash YYYY
Is the patient pregnant or think they may be?*
Does the patient have or have they had any of the following?

Dental History

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Is the patient anxious or nervous about dental treatment?*
Does the patient require premedication for dental treatment?*
Does the patient feel pain in any of their teeth?*
Does the patient have any sores or lumps in or near their mouth?*
Has the patient had any head, neck, or jaw injuries?*
Does the patient have any ongoing problems in their jaw with:
Does the patient clench or grind their teeth?*
Does the patient bite their lips or cheeks frequently?*
Has the patient ever had speech therapy?*
Is there any outstanding dental Treatment to be completed?*
Has the patient ever had instruction on the correct method of brushing and flossing their teeth?*
Does the patient have any of the following oral habits:
How many times a day does the patient brush?*
Please check the boxes below which describe the problem(s) for which the patient is seeking treatment for:*
Has the patient had an orthodontic Evaluation or treatment before?*

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Authorization and Release

TO THE BEST OF MY KNOWLEDGE THE ABOVE QUESTIONS HAVE BEEN ACCURATELY ANSWERED AND IT IS MY RESPONSIBILITY TO INFORM THIS OFFICE OF ANY CHANGES TO THE PATIENT’S MEDICAL STATUS. I GIVE LIMBAUGH ORTHODONTICS PERMISSION TO PERFORM AN ORTHODONTIC EXAMINATION.

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