Online Patient Health History Form


Submit Your Health History Form Online to Your Orthodontist


Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form, click the "Submit Form" button at the bottom, and your information will be sent to our office with secure encryption. We will already have your information when you arrive for your first appointment. You will need to provide a signature at the office to verify that the information you submitted online is accurate.


This website is compliant with the Health Insurance Portability and Accountability Act (HIPAA). All of your personal health information is confidential, and will not be shared with anyone, aside from those involved in your treatment, without your consent.


Patient Information


Items marked with asterisk (*) must be completed.
First Name*
Middle Initial
Last Name*
I prefer to be called (Nickname)
Address*
Street
City
State/Province
Zip/Postal Code
Country
Cell Phone*--
Home/Other Phone*--
Work Phone--
Email Address*
Birthdate (MM-DD-YYYY)*--
Gender*
If patient is a minor, give both parents or guardian's names here*
Whom may we thank for referring you to our office?*
Do you have any other family members in our practice?

Responsible Party Information
Full Name*
Mailing Address (if different than patient)
Street
City
State/Province
Zip/Postal Code
Country
Cell/Other Phone (if different than patient)--
Home/Other Phone (if different from patient)--
Work Phone--
Email Address (if different from patient)


If patient is under 18, please complete this section.
2nd Parent/Guardian's Name
Relationship to Patient
Address of 2nd Responsible Party (if different than patient)
Street
City
State
Zip
Cell Phone --
Home/Other Phone--
Work Phone--
Email Address (if different than patient)

Dental Insurance Information
Primary Insured's ID number
Primary Insured's Name
Primary Insured's Social Security Number (U.S. only)--
Primary's Insurance Company
Primary's Group Number
Primary's Local Number
Primary Insurance Company Address
Street
City
State/Province
Zip/Postal Code
Country
Primary Insurance Phone Number--
Secondary Insured's Name
Secondary Insured's Social Security Number (U.S. only)--
Secondary's Insurance Company
Secondary's Group Number
Secondary's Insurance Local Number
Seconeary Insurance Company Address
Street
City
State/Province
Zip/Postal Code
Country
Secondary Insurance Phone Number--

Emergency Information (if patient is an adult)
Name of the nearest relative not living with you
Phone--

Medical History


Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.
Physician*
Address
Street
City
State/Province
Zip/Postal Code
Country
Phone*--


Please check any of the following which apply to you, and add any relevant comments.
Are you taking any medication?*
Are you allergic to any medication?*
Do you have a history of any major illness?*
Have you had any major operations?*
Have you ever been involved in a serious accident?*


Please check any of the following that you have had or currently have:
If you marked yes to any of the above, please add any additional comments here. Are there any medical conditions we have not discussed that you feel we should be aware of?

Dental History
Dentist*
Date of Last Visit--
What concerns you most about your teeth?*


Please check any of the following which apply to you, and add any relevant comments.
Comment:
Comment:
Comment:
Comment:
Comment:
Comment:
Comment:
Comment:
If yes, When?
What is your attitude toward receiving orthodontic treatment?
How did they feel about the result?
What is your attitude toward receiving orthodontic treatment?
Comment:
Comment:
Comment:
Comment:
Comment:
Comment:


By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.