Patient information form – Dr. Rick Odegaard Orthodontist

Patient Information

Patient Name

Parent/Guardian Name

Additional Parent/Guardian Name

Age

Date of Birth

Sex

Address

City

Province

Postal Code

Phone (Home)

Phone (Cell)

Phone (Work)

Dentist

Physician

Who may we thank for referring you?

Account Information Personal responsible for account

Title

Name

Email Address

Address

City

Province

Postal Code

Dental Insurance

We do not bill dental insurance companies directly. Payment from the responsible party is required at the time the service is provided. We will aid you with preparing your insurance claims so that you may receive reimbursement directly from your insurance company.

Enter insurance policy information

Insurance Policy #1

Name of Policy Holder

Relationship to Patient

Address

City

Province

Postal Code

Date of Birth

Employer

Insurance Company

Group

ID/Certificate

Patient's Dependent #

% Ortho Coverage

Coverage Limit

Insurance Policy #2

Name of Policy Holder

Relationship to Patient

Address

City

Province

Postal Code

Date of Birth

Employer

Insurance Company

Group

ID/Certificate

Patient's Dependent #

% Ortho Coverage

Coverage Limit

Medical History

Is the patient in good health?

yes

Is the patient under a physician's care?

yes

If yes, briefly describe

Please list any drugs and/or medications being taken

Give reasons

Does the patient have any allergies or drug sensitivities

Does the patient require antibiotic premedication before dental treatment?

yes

Have the tonsils/adenoids been removed?

yes

If so, what age?

Dental History

Has there ever been any injury to the face, mouth, or teeth?

yes

If yes, please briefly describe

Has the patient ever sucked a thumb or finger?

yes

Is the patient a mouth breather?

awake

sleeping

both

Has the patient ever been informed of any missing or extra teeth?

yes

Has the patient ever had a previous orthodontic exam?

yes

Do any relatives have a similar tooth or jaw condition as the patient?

yes

If yes, please briefly describe

Has any family member been previously treated in this office?

When did the patient last have dental care?

Briefly state what you would like to achieve with orthodontic treatment

Please list any sports, hobbies, and/or interests

ANY INFORMATION PROVIDED WILL BE HELD IN STRICTEST CONFIDENCE.
PLEASE INFORM THE OFFICE IF ANY OF THE ABOVE INFORMATION CHANGES DURING THE COURSE OF TREATMENT.

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