Limbaugh Orthodontics

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?
- Valpak
- Dentist
- Google
- Website
- Friend
- Family
- Other
Name of Friend*
Name of Family Member*
Name of Referral*
Marital Status*
- Married
- Separated
- Divorced
- Widowed
- Single
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?
- Valpak
- Dentist
- Google
- Website
- Friend
- Family
- Other
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?*
- Married
- Seperated
- Divorced
- Widowed
- Single
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*
Hidden
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*
Hidden
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
MM slash DD slash YYYY
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*
MM slash DD slash YYYY
Is the patient pregnant or think they may be?*
- Yes
- No
Does the patient have or have they had any of the following?
- Hay Fever / Allergies
- Cold Sores
- Migraines
- Diabetes / Glaucoma
- Rheumatic Fever
- Aids Or Hiv Infection
- Cardiac Pacemaker
- Asthma (Inhaler)
- Fainting / Seizures
- Thyroid Problem
- High / Low Blood Pressure
- Heart Trouble
- Epilepsy / Convulsions
- Leukemia
- Kidney / Liver Disease
- Anemia
- Cancer
- Joint Replacement Or Implant
- Hepatitis / Jaundice
- Stomach Troubles / Ulcers
- Stroke
- Radiation Therapy
- Respiratory Problems
- Removal Of Adenoids Or Tonsils
- Sinus Problems
- Bone Disorder
- Osteopenia/Osteoporosis
- Taking Medication:
If taking medication, please specify:
Dental History
Dentist's Name*
Date of last cleaning? (approximate)
MM slash DD slash YYYY
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:*
- Crowding
- Extra space
- Teeth stick out too far
- TMJ problems
- Poor bite relationship
- Missing teeth
- Teeth erupting in the wrong position
- Extra permanent teeth
- Other
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)*
Comments
This field is for validation purposes and should be left unchanged.

Name	Birthdate

Patient Information (Adult)

Spouse Information

Patient Information (Child)

Responsible Party

Mother's Information

Father's Information

Guardian's Information

Male

Female

Primary Insurance Information

Secondary Insurance Information

Emergency Contact Information

Medical History

Dental History

Authorization and Release