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Thomas & Leitner Orthodontics
Is the patient a minor?
*
Yes
No
Patient Information
Name
*
Date of birth
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Gender
*
Male
Female
School
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Grade
K
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Home Phone
Cell Phone
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Street Address
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City
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State
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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
*
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
Month
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Day
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1926
1925
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1923
1922
1921
1920
Social Security Number
Same address as patient
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
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
*
Month
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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
*
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1920
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
*
Month
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Day
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2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
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1998
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1986
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1932
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1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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
Phone
This field is for validation purposes and should be left unchanged.