Mary Cay Koen Orthodontics

Is the patient a minor?*
- Yes
- No
Patient Information - Child
Name*
Preferred Name
Gender*
- Male
- Female
Date of Birth*
Grade*
School Attending*
Home Phone
Cell Phone*
Street Address*
City*
State*
ZIP*
Name / Relationship of person accompanying patient to the appointment*
Who has legal custody of patient?*
Name of siblings and ages
Sibling Name Sibling Age
Have we treated any of the patient's family members?*
- Yes
- No
If yes, who?*
Whom may we thank for referring you?
- Valpak
- Dentist
- Google
- Website
- Friend
- Family
- Other
Name of Friend*
Name of Family Member*
Name of Referral*
Patient Information - Adult
Name*
Preferred Name*
Date of Birth*
Gender*
- Male
- Female
Home Phone
Cell Phone*
Email*
Street Address*
City*
State*
ZIP*
SSN
How long at this address*
Employer
Occupation
Employer Address
Employer City
Employer State
Employer ZIP
Work Phone
Number of years employed?
Have we treated any family members?*
- Yes
- No
If yes, who?*
Marital Status*
- Married
- Separated
- Divorced
- Widowed
- Single
Whom may we thank for referring you?
- Valpak
- Dentist
- Google
- Website
- Friend
- Family
- Other
Name of Friend*
Name of Family Member*
Name of Referral*
Financially Responsible Party
Who will be the financially primary responsible party for the patient’s orthodontic treatment?*
- Both Parents
- Mother only
- Father only
- Guardian
Is the patient's Guardian a Male or Female?
- Male
- Female
Marital Status*
- Married
- Separated
- Divorced
- Widowed
- Single
Mother's Information
- Same as patient address
Relationship to Child*
*Note* If the financially responsible party is the stepmother or a female guardian, simply select the stepmother or female guardian option and fill in their information under the 'Mother' fields.
- Parent
- Guardian
- Step Mother
Mother's Name*
Mother's Date of Birth*
Mother's SSN
Mother's Street Address*
Mother's City*
Mother's State*
Mother's ZIP*
How many years at this address?*
Mother's Cell Phone*
Mother's Work Phone
Mother's Employer
Years Employed
Mother's Occupation
Mother's Email*
Father's Information
- Same as patient address
Relationship to Child*
*Note* If the financially responsible party is the stepfather or a male guardian, simply select the stepfather or male guardian option and fill in their information under the 'Father' fields.
- Parent
- Guardian
- Step Father
Father's Name*
Father's Date of Birth*
Father's SSN
Father's Street Address*
Father's City*
Father's State*
Father's ZIP*
How many years at this address?*
Father's Cell Phone*
Father's Work Phone
Father's Employer
Years Employed
Father's Occupation
Father's Email*
Spouse Information
- Same as patient address
Spouse's Name*
Spouse's Date of Birth*
Spouse's SSN
Spouse's Employer
Spouse's Occupation
Employer's Address
Employer's City
State
ZIP
Number of years employed
Work Phone
Cell Phone*
Home Phone
Email
Insurance Options
Select your Dental Insurance option
- Primary Dental Insurance Only
- Primary and Secondary Dental Insurance
- No Dental Insurance
Primary Dental Insurance
Insurance Company
Insurance Phone Number
Employer / Group Name
Group Number
Subscriber / Employee
Subscriber ID / SSN
Subscriber's Date of Birth
Relationship to Patient
Secondary Dental 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 relationship not living with the patient*
If the patient is a minor, do not list anyone from the financially responsible party.
Relationship to the Patient*
Home Phone
Cell 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.
Medical History
Physician's Name*
Physician's Phone*
Date of last 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 menstruation begun?*
- Yes
- No
If yes, please date:
MM slash DD slash YYYY
Is the patient pregnant or think they may be?*
- Yes
- No
Has the patient ever taken Bisphosphonates (EX: Fosamax) for Osteoporosis?*
- Yes
- No
If yes, specify:*
Has the patient reached puberty?*
- 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 the patient is taking a form of 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?*
- 0
- 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
Please list who we can share information with
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 MCKOEN ORTHO PERMISSION TO PERFORM AN ORTHODONTIC EXAMINATION.
Print Name*
This is the name of the person filling out the form and providing the signature below.
Relationship to Patient*
If the person filling out the form is the patient, then write "Self"
Signature of Patient (or Responsible Party if the patient is a minor)*
Name
This field is for validation purposes and should be left unchanged.

Sibling Name	Sibling Age

Patient Information - Child

Patient Information - Adult

Financially Responsible Party

Mother's Information

Father's Information

Spouse Information

Insurance Options

Primary Dental Insurance

Secondary Dental Insurance

Emergency Contact Information

Please Read

Medical History

Dental History

Authorization and Release