ADULT Orthodontic Health History Form
Today’s Date ________________
Patient’s Last Name _______________________________ First _______________________ MI ______
DOB: ______________ Age: __________ Sex: ________ “I prefer to be called ___________________”
Home Ph. #: __________________ Cell Ph. #: ________________ Work Ph. #: _____________________
Email Address/es: ________________________________________________________________________
Best Method for Appt. Confirmations (circle): EMAIL Home Ph. Cell Ph. Work Ph. Cell Text
Patient’s Full Address: ____________________________________________________________________
List Names of Other Family Members Treated Here: ________________________________________
Person Financially Responsible for this Patient Account: ____________________________________
Do you have Insurance Coverage for Orthodontic Treatment? _____________________________
PRIMARY INSURANCE
Name of Policy Holder: __________________________________ Employer: ______________________
Insurance Co. Name & Address: __________________________________________________________
SSN/ ID#: ______________________ DOB: ___________________ Group #: ________________________
SECONDARY INSURANCE
Name of Policy Holder: __________________________________ Employer: ______________________
Insurance Co. Name & Address: __________________________________________________________
SSN/ ID#: ______________________ DOB: ___________________ Group #: ________________________
Did your Dentist Recommend Orthodontic Treatment? Yes _____ or No _____
How did you hear about Family Orthodontics at KidZdent? _________________________________
Dentist Name: ____________________ Town: _______________________ Ph. #: ____________________
Date Last Seen by Dentist and Reason for Visit: _____________________________________________
Do you have any Dental Work that needs to be completed? _______________________________
Tell us a little bit about yourself…
• What do you like about your smile? ____________________________________________________
• What concerns you most about your smile? ____________________________________________
• What types of braces are you interested in? Traditional___ Clear___ Invisalign ___
• Is there a target date you expect your treatment to be completed by? __________________
• What hobbies or sports do you enjoy? __________________________________________________