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Limbaugh Orthodontics
Which form are you using?
*
Adult
Child
Patient Information (Adult)
Name
*
Preferred Name
Gender
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Male
Female
Date of Birth
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Social Security Number
Cell Phone
*
Home Phone
Street Address
*
City
*
State
*
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP Code
*
Email
*
How many years at this address?
*
Employer
Occupation
Employer's Street Address
Employer's City
Employer's State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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
*
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Social Security Number
Employer
Occupation
Employer Street Address
City
State
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AR
CA
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CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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
*
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School Attends
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Grade
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PK
K
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Street Address
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City
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State
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CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP Code
*
Cell Phone
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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
*
Month
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Mother's Social Security Number
Street Address
*
City
*
State
*
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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
*
Month
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1921
1920
Father's Social Security Number
Street Address
*
City
*
State
*
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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
*
Month
1
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Social Security Number
Street Address
*
City
*
State
*
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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
*
Month
1
2
3
4
5
6
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10
11
12
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1935
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Social Security Number
Street Address
*
City
*
State
*
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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
*
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1935
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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
*
Month
1
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1920
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?
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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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Signature of Patient (or Parent if minor)
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