Limbaugh Orthodontics – Secure Forms Host

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.

Name of Family Member*

Mother's Information

Mother's Social Security Number

How many years at this address?*

Mother's Cell Phone*

Father's Information

Father's Social Security Number

How many years at this address?*

Father's Cell Phone*

Guardian's Information

Social Security Number

How many years at this address?*

Social Security Number

How many years at this address?*

Primary Insurance Information

Insurance Phone Number*

Employer/Group Name*

Subscriber/Employee*

Relationship To Patient*

Secondary Insurance Information

Insurance Phone Number*

Employer/Group Name*

Subscriber/Employee*

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

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.

Date of last physical exam

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

If yes, what medications is the patient taking?*

If yes, please date*

If taking medication, please specify:

Date of last cleaning? (approximate)

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

Please describe the patient's speech therapy?*

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

What other problem:*

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)*

Name

This field is for validation purposes and should be left unchanged.

Electronic Form

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