Thomas & Leitner Orthodontics – Secure Forms Host

Is the patient a minor?*

Yes
No

Patient Information

Name*

Date of birth*

Gender*

Male
Female

School*

Grade

Home Phone

Cell Phone*

Street Address*

City*

State*

ZIP*

Social Security Number

Email*

Whom may we thank for referring the patient?

Name of Friend*

Name of Family Member*

Name of Referral*

If Patient is a Minor

Name/Relationship of person accompanying patient to today's appointment*

Patient lives with whom/relationship*

Who has legal custody of the patient?*

Names of Siblings and Ages

Name	Birthdate

Responsible Party

Responsible Party's Name*

If the patient's responsible party is themselves, insert the patient's name

Marital Status of Responsible Party*

Cell Phone

Work Phone

Email

Home Phone

Responsible Party's Date of birth

Social Security Number

Same address as patient

Street Address

City

State

ZIP

How many years at this address?

Does the responsible party rent or own the current residence?

Rent
Own

Previous address (if the responsible party has lived at the current address for less than two years)

Please provide full address with City, State and Zip.

Employer

Occupation

Number of years employed*

Spouse's Information

Spouse's Name*

Spouse's relationship to the patient*

Spouse's Social Security Number

Spouse's date of birth*

Work Phone*

Cell Phone*

Does the patient have Primary and Secondary Insurance?*

Primary Insurance Only
Primary and Secondary Insurance
No Insurance

Primary Insurance Information

Employer*

Policy ID Number*

Insurance Company*

Group Number*

Insurance Company Address*

Insurance Phone Number*

Subscriber Name*

Subscriber date of birth*

How is the insurance subscriber related to the patient?*

Secondary Insurance Information

Employer*

Policy ID Number*

Insurance Company*

Group Number*

Insurance Company Address*

Insurance Phone Number*

Subscriber Name*

Subscriber's Date of Birth*

How is the insurance subscriber related to the patient?*

Emergency Contact Information

Nearest relative not living with the patient*

Relationship to patient*

Home Phone

Cell Phone*

Medical History

PLEASE READ: We are passionate about our mission to give everyone a beautiful smile. Please help us to help you and your child by letting us know of any delayed development, social disabilities, ADD or ADHD, Bipolar, Autism, etc.

Physician 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?*

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?

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

If yes, please describe*

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 an of the following oral habits?

Nail Biting
Thumb Sucking
Tongue Thrust While Swallowing
Mouth Breathing

How many times a day does the patient brush their teeth?*

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?*

How does the patient feel about braces/Invisalign?*

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 THOMAS & LEITNER ORTHODONTICS PERMISSION TO PERFORM THE NECESSARY DENTAL SERVICES THAT THE PATIENT MAY NEED.

PHOTO RELEASE

WE WILL BE DOCUMENTING YOUR SMILE TRANSFORMATION WITH PHOTOS, POSSIBLE VIDEOS AND DENTAL MODELS TO CELEBRATE YOUR RESULTS. WE OCCASIONALLY SPOTLIGHT PATIENTS ON OUR WEBSITE, WITHIN THE OFFICE, AND OTHER PRACTICE SITES (FACEBOOK, BLOG, ETC) AND REQUEST YOUR AUTHORIZATION BELOW. I, THE UNDERSIGNED, DO HEREBY RELINQUISH ANY AND ALL RIGHTS TO PHOTOGRAPHS, PORTRAITS, PRINTS, NEGATIVES, OR OTHER PHOTOGRAPHIC REPRODUCTIONS CAPTURED WITH STILL MOTION PICTURE, VIDEO, DIGITAL OR OTHER CAMERAS FOR USE BY THOMAS & LEITNER ORTHODONTICS.

Signature of patient (or parent if minor)*

Parent/Guardian Name

Relationship to patient

Acknowledgement of Receipt of Notice of Privacy Practices

*You may refuse to sign this agreement.

Submit yes if the patient (or parent if minor) agrees to the following statment*

I have received a copy of this office's notice of privacy practices.

Yes
No

Name

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