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Health/Dental History

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The following information is for a(n):*
What helped you decide to come to Prine Orthodontics?*
Sex:*
Address:*


Would you like a text reminder 2 days prior to all appointments?
Would you like an email reminder 5 days prior to all appointments?
Marital Status:*
Parents' Marital Status:*
Are there other children in the Family?*
Have they undergone orthodontic treatment?
Have they undergone orthodontic treatment?
Have they undergone orthodontic treatment?
Have they undergone orthodontic treatment?
Have they undergone orthodontic treatment?
Do you have children?*
Person Responsible for Account:*
Person Responsible for Account:

HIPAA Consent

This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Consent Person or direct your questions to this person at our office address.*

Dental Insurance

Do you have Dental Insurance?*

Failure to provide Member ID# & SS# for insurance may result in treatment being quoted without insurance. If this occurs, You will be responsible for filing your insurance with your insurance company.

Ortho Coverage:
Do you have Secondary Insurance?*
Ortho Coverage:

Dental History

Do you have a Dentist?*
Have there been any injuries to the face, mouth or teeth?
Have you had or do you presently have any of the following habits?
Have you been informed of any missing or extra permanent teeth?*
Are you aware of sores, lumps or irritated areas in the mouth?*
Has an orthodontist been consulted previously?*
Have you ever been treated for:*
Are you frightened or anxious about Orthodontic treatment?*
Are you concerned about the appearance of your teeth?*
Do you have any speech problems?*
Is there anything you would like to change about your smile?*
What aspect of dental treatment are you most concerned with?*
Has there ever been any orthodontic treatment for any other member of your family?
Were they satisfied with the results?
Were they satisfied with the results?
Were they satisfied with the results?

Medical History

Is your general health good at this time?*
Are you under the care of a physician at this time?*
Are you taking any medication?*
Are you allergic to any medication? (Penicillin, Sulfa, etc.)*
Have you ever taken any diet medication (Fen-Phen)?*
Have you ever had a serious illness or been hospitalized?*
Have you had your tonsils and/or adenoids removed?*
Do you have any special problems not listed?*
Do you currently take an antibiotic prior to dental treatments? (Pre-Med)*

Medical History

Do you use tobacco? (smoking or chewing)*
Have you recently noticed a growth spurt?
Are you pregnant?*
Are you currently taking medication for birth control?*
Are you nursing?*

DO YOU HAVE NOW, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?

Please check if YES or leave unchecked for NO:
Please check if YES or leave unchecked for NO:
Please check if YES or leave unchecked for NO:
I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION. I grant authority to the Doctor and Staff to perform all procedures and treatments in my best interest. I authorize the Orthodontist to share treatment information with collaborating dentists and surgeons when appropriate. I authorize the Orthodontist to submit treatment information pertinent to this patient to the Insurance Company for billing purposes only. I understand that, when appropriate, Credit Bureau reports may be obtained.

Prine Orthodontics may use your orthodontic records for educational and promotional purposes. I know this is in the Consent form, but it allows us to use their photos, etc. for teaching purposes even if they do not start treatment.
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