Thomas & Leitner Orthodontics

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?
- Valpak
- Dentist
- Google
- Website
- Friend
- Family
- Other
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*
- Married
- Separated
- Divorced
- Widowed
- Single
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
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?*
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
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
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:
- 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?*
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
Comments
This field is for validation purposes and should be left unchanged.

Name	Birthdate

Patient Information

If Patient is a Minor

Responsible Party

Spouse's Information

Primary Insurance Information

Secondary Insurance Information

Emergency Contact Information

Medical History

Dental History

Authorization and Release

PHOTO RELEASE

Acknowledgement of Receipt of Notice of Privacy Practices