MEDICAL DENTAL HISTORY FORM

CONFIDENTIAL
(Please fill out the form completely)		 En Español
Patient is:
Child    Adult    Single    Married
Last Name
 First Name
 MI
 Sex:
Male   Female
Social Security #:
- - 		Date of Birth:
/ / 		Age:
 I prefer to be called:
Home Phone
( ) - 		Mobile Phone (Other)
) - 		Email Address
Patient's Address
 Apt/Suite#:
City
 State
 Zip
 Years at this address:
If less than 5 years, Previous Address:
 Apt/Suite#:
City
 State
 Zip
 Years at this address:
Patients Responsible Party Information
Primary Last Name
 Primary First Name
Date of Birth:
/ / 		Driver's License #:
 Exp. Date:
/ /
Relationship to patient:
 Email Address:
Social Security #:
- -
Occupation:
 Employer:
 Years:
 Phone #:
( ) -
Secondary Last Name
 Secondary First Name
Date of Birth:
/ / 		Driver's License #:
 Exp. Date:
/ /
Relationship to patient:
 Email Address:
Social Security #:
- -
Occupation:
 Employer:
 Years:
 Phone #:
( ) -
Closest Relative Last Name
 Closest Relative First Name
Relationship to patient:
 Phone #:
( ) -
Address:
Financial Responsible Party (if different from above)
Last Name
 First Name
Date of Birth:
/ / 		Driver's License #:
 Exp. Date:
/ /
Relationship to patient:
 Email Address:
Social Security #:
- -
Occupation:
 Employer:
 Years:
 Phone #:
( ) -
Patient Dental Information
Dentist Name:
 Phone #:
( ) -
Address
 Room/Suite#:
City
 State
 Zip
Date last seen:
/ / 		Reason:
Who suggested that you might need orthodontic treatment?
 Why did you select our office?
Insurance Information
Insurance Coverage for Dental Treatment?
Yes   No		 Insurance Coverage for Orthodontic Treatment?
Yes   No
Primary Policy Holder's Name:
 SSN/SIN/Enrollee #:
 Date of Birth:
/ /
Employer Name and Address:
Dental Insurance Company:
 Effective Date:
/ / 		Group #:
Secondary Policy Holder's Name:
 SSN/SIN/Enrollee #:
 Date of Birth:
/ /
Employer Name and Address:
Insurance Company:
 Effective Date:
/ / 		Group #:

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