Limbaugh Orthodontics – Secure Forms Host

Which form are you using?*

Adult
Child

Patient Information (Adult)

Name*

Preferred Name

Gender*

Male
Female

Date of Birth*

Social Security Number

Cell Phone*

Home Phone

Street Address*

City*

State*

ZIP Code*

Email*

How many years at this address?*

Employer

Occupation

Employer's Street Address

Employer's City

Employer's State

Employer's ZIP Code

Work Phone

Number of years employed?

Whom may we thank for referring you?

Name of Friend*

Name of Family Member*

Name of Referral*

Marital Status*

Spouse Information

Spouse's Name*

Spouse's Date of Birth*

Social Security Number

Employer

Occupation

Employer Street Address

City

State

ZIP Code

Employer's Work Phone

Numer of Years Employed?

Spouse's Work Phone

Spouse's Cell Phone*

Email*

Patient Information (Child)

Name*

Preferred Name

Gender*

Male
Female

Date of Birth*

School Attends*

Grade*

Street Address*

City*

State*

ZIP Code*

Cell Phone*

Home Phone

Name/Relationship of person accompanying patient to today's appointment*

Patient Lives With Whom?*

Names please.

Relationship To The Patient*

Parent, Step-Parent, Grand Parent, etc.

Who Has The Legal Custody Of The Patient?*

Names please.

Names Of Siblings and Birthdates

Name	Birthdate

Whom my we thank for referring you?

Name of Friend*

Name of Family Member*

Name of Referral*

Responsible Party

Who will be the primary responsible party for the patient’s orthodontic treatment?*

Both Parents
Mother only
Father only
Guardian

Marital Status of Responsible Party?*

Mother's Information

Same address as patient

Mother's Name*

Mother's Relationship*

Parent
Guardian
Step Mother

Mother's Date of Birth*

Mother's Social Security Number

Street Address*

City*

State*

ZIP Code*

How many years at this address?*

Mother's Work Phone

Mother's Cell Phone*

Mother's Employer

Years Employed

Mother's Occupation

Mother's Email*

Father's Information

Same address as patient

Father's Name*

Father's Relationship*

Parent
Guardian
Step Father

Father's Date of Birth*

Father's Social Security Number

Street Address*

City*

State*

ZIP Code*

How many years at this address?*

Father's Work Phone

Father's Cell Phone*

Father's Employer

Years Employed

Father's Occupation

Father's Email*

Guardian's Information

Guardian's Gender*

Male
Female

Male

Same address as patient

Guardian's Name*

Relationship to Patient*

Father
Guardian
Step Father

Guardian's Date of Birth*

Social Security Number

Street Address*

City*

State*

ZIP Code*

How many years at this address?*

Cell Phone*

Work Phone

Employer

Years Employed

Occupation

Email*

Female

Same address as patient

Guardian's Name*

Relationship to Patient*

Mother
Guardian
Step Mother

Guardian's Date of Birth*

Social Security Number

Street Address*

City*

State*

ZIP Code*

How many years at this address?*

Cell Phone*

Work Phone

Employer

Years Employed

Occupation

Email*

Primary Insurance Information

Insurance?

Check here if no orthodontic coverage will be applied

Insurance Company*

Insurance Phone Number*

Employer/Group Name*

Group Number*

Subscriber/Employee*

Subscriber ID/SSN*

Subscriber's Date of Birth*

Relationship To Patient*

Secondary Insurance Information

Secondary Insurance?

Check here if no secondary insurance

Insurance Company*

Insurance Phone Number*

Employer/Group Name*

Group Number*

Subscriber/Employee*

Subscriber ID/SSN*

Subscriber's Date of Birth*

Relationship To Patient*

Emergency Contact Information

Nearest Relative Not Living With Patient*

Nearest Relative's Relationship To Patient*

Nearest Relative's Cell Phone*

Nearest Relative's Home Phone

Medical History

Please Read:

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.

Physician's Name*

Physician's Phone*

Date of last physical exam

Is the patient under medical treatment now?*

Yes
No

Has the patient been hospitalized for any surgical operations or serious illness in the past five years?*

Yes
No

Please describe the surgical operation(s) or illness(es).*

Is the patient taking medication(s) including non-prescription medicine?*

Yes
No

If yes, what medications is the patient taking?*

Does the patient use tobacco?*

Yes
No

Is the patient aware of being allergic to any medications or substance including metals?*

Yes
No

If yes, what?*

Has the patient ever taken Bisphosphonates (EX: Fosamax) for Osteoporosis?*

Yes
No

If yes, specify

Has the patient reached puberty?*

Yes
No

Has menstruation begun?*

Yes
No

If yes, please date*

Is the patient pregnant or think they may be?*

Yes
No

Does the patient have or have they had any of the following?

If taking medication, please specify:

Dental History

Dentist's Name*

Date of last cleaning? (approximate)

Is the patient anxious or nervous about dental treatment?*

Yes
No

Does the patient require premedication for dental treatment?*

Yes
No

Does the patient feel pain in any of their teeth?*

Yes
No

Does the patient have any sores or lumps in or near their mouth?*

Yes
No

Has the patient had any head, neck, or jaw injuries?*

Yes
No

If the patient has had any head, neck, or jaw injuries, please describe:*

Does the patient have any ongoing problems in their jaw with:

Chronic clicking or popping?
Pain?
Difficulty opening or closing?
Difficulty in chewing?

Does the patient clench or grind their teeth?*

Yes
No

Does the patient bite their lips or cheeks frequently?*

Yes
No

Has the patient ever had speech therapy?*

Yes
No

Please describe the patient's speech therapy?*

Is there any outstanding dental Treatment to be completed?*

Yes
No

If yes, there is outstanding dental Treatment to be completed, describe:*

Has the patient ever had instruction on the correct method of brushing and flossing their teeth?*

Yes
No

Does the patient have any of the following oral habits:

Nail biting?
Thumb sucking?
Tongue thrust while swallowing?
Mouth breathing?

How many times a day does the patient brush?*

1
2
3+

Please check the boxes below which describe the problem(s) for which the patient is seeking treatment for:*

What other problem:*

Has the patient had an orthodontic Evaluation or treatment before?*

Yes
No

If so, when and by whom?*

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.

Print Name*

This is name of person filling out the form and providing signature.

Relationship to Patient*

Signature of Patient (or Parent if minor)*

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Name

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