Mary Cay Koen Orthodontics – Secure Forms Host

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?

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*

Whom may we thank for referring you?

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*

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

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:

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?

If the patient is taking a form of 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?*

0
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

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.