Registration form (Please Print) Welcome to Santa Clarita Orthodontics!



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PATIENT REGISTRATION FORM (Please Print)

Welcome to Santa Clarita Orthodontics!

Federal and state laws require us to obtain the following confidential information with 2 forms of identification. Also, to give you the best consideration of your orthodontic needs and to thoroughly diagnose any condition, we must have accurate background and health information. Please circle the appropriate response where indicated. Thank you.
PATIENT INFORMATION
Patient Name _______________________________ Age _____ Birth date _____________ Sex M F

Home Address ____________________________________________________________________

City__________________________________________State_____________Zip______________

Prim. Phone ( ) _______________HW CAlter. Phone ( )_______________ H W C

Family Dentist ________________Ph#____________ Family Physician_________________________

Referred by _________________________Email(appt. notification)___________________________

Custodial Parent Primarily Responsible for Account ______________________________________Relationship__________

Date of Birth ____________________________________________ Social Security Number _____________________

Home Address (if different from pt)________________________________________________________________

Occupation ________________________ Email __________________________________________________

Employer Name & Address ___________________________________________________________________________

Is patient covered by insurance for orthodontic treatment under this person? Yes No

If yes, name of insurance carrier? ____________________________________________________________________

ID # ____________________________ Group #________________________________________________________

Secondary Person (or non-custodial) Resp. for Account ___________________________________ Relationship________

Date of Birth __________________________________________Social Security Number ________________________

Home Address (if different from pt)____________________________________________________________________

Occupation ________________________ Email ___________________________________________________

Employer Name & Address____________________________________________________________________________

Is patient covered by insurance for orthodontic treatment under this person? Yes No

If yes, name of insurance carrier? ____________________________________________________________________

ID # ____________________________ Group # ________________________________________________________

MINOR PATIENT’S FAMILY HISTORY – Patient lives with ______________________Relationship to pt______________

If a minor: Father’s Name ______________________________Mother’s Name____________________________________

Siblings: None _____ # of Brothers _____ # of Sisters Parents Marital Status ____________________________
PATIENT’S MEDICAL HISTORY - Has patient ever had:

Asthma Diabetes Heart Disease Hepatitis

Anemia Epilepsy Hearing Disease Rheumatic Fever

Blood Disease Endocrine Problems Head or Face Injury A.I.D.S

Bone Disorders Emotional Problems Herpes Other (describe below)

Comments: _________________________________________________________________________________________

Has the patient been under the care of a physician during the past two years, other than for routine examinations? Yes No

OVER

Condition: _____________________________________________________________________________________________________________

Present drugs or medication:________________________________________________________

Birth Defects: __________________________________________________________________

Has the patient reached puberty (menstruation, pubic hair) Yes No



RESPIRATORY HISTORY - Does the patient:

  1. Have allergies to: Seasonal grasses Food

Drugs Other

  1. Snore while sleeping? Yes No

  2. Mouth Breather? Yes No

  3. Have frequent colds? Yes No

  4. Have frequent stuffy nose? Yes No

  5. Have frequent sore throat or tonsillitis? Yes No

  6. Have chewing or swallowing difficulties? Yes No

DENTAL HISTORY

Does the patient have pain or clicking in jaw joint? Yes No

Have any teeth been injured due to accidents or blows to the mouth? Yes No


Date of injury:____________________________________

Has the patient received or requested to receive speech correction? Yes No

The following habits are of interest. List information as it pertains to this patient:

Thumb or Finger sucking? Yes No Grinding of teeth? Yes No

Lip Biting or sucking? Yes No Tongue thrust? Yes No

Others (specify):



Has the patient had any unusual dental experiences?

Specify:



Date of last dental checkup: _______ Were the patient’s teeth cleaned? Yes No

ORTHODONTIC HISTORY


Has the patient had a previous Orthodontic consultation? Yes No

Has the patient had previous Orthodontic treatment? Yes No

Date: Doctor: ________

Orthodontic consultation prompted by? Patient Dentist Mother Father Spouse

Siblings Physician Friend Other (specify): ________

Patient’s interest in orthodontic treatment:

Excited about starting treatment___Neutral about treatment___Against having treatment___

What prompted this consultation? ________

What is the primary concern? ________

What is expected from orthodontic treatment? ________

Additional comments you wish to make? ________



________

_____________________________________________________________________________



Signature of individual completing this form: ________

Relationship to patient: Today’s Date: ________


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