Havener Orthodontics
Email: info@havenerorthodontics.com
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Menu
Home
Resources
Common Problems
Emergencies
Blog
New Patient Forms
New Patient Form – Adult
New Patient Form – Under 18
Contact Us
New Patient Form – Under 18
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Patient
Patient Name
First
Middle
Last
Prefers To Be Called
Hobbies, Activities
Birth Date
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
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11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
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1952
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1948
1947
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1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Age
Sex
Male
Female
Social Security Number
School
Grade
Email
Home Address
City, State, Zip
Home Phone
Cell Phone
Parent/Gaurdian
Custodial Parent's Name
Patient Lives With:
mother
father
stepmother
stepfather
other
grandparent(s)
Check all that apply
If Other, What is the Relationship?
Father's Full Name
Father's Title
Mr.
Dr.
Other
If Other
Father's Occupation
Father's Email Address
Father's Address (if different)
Father's Cell Phone (if different)
Father's Home Phone (if different)
Father's Work Phone
Mother's Full Name
Mother's Title
Mrs.
Ms.
Dr.
Other
If Other
Mother's Occupation
Mother's Email Address
Mother's Address (if different)
Mother's Cell Phone (if different)
Mother's Home Phone (if different)
Mother's Work Phone
Patient's Dentist
Patient's Dentist
Address, City, State
Date Last Seen
Reason
Next Appointment Date
General Information
What concerns you about your child's teeth?
What concerns your child about his/her teeth?
How does your child feel about orthodontic treatment?
Why did you select our office?
Does your child play a musical instrument?
Yes
No
Have any other family members been treated in this office?
Yes
No
If yes, please name them:
Financial Responsibility
Who is financially responsible for this account?
Home Address
City, State, Zip
Home Phone
Cell Phone
Email
Social Security Number
Employer
Who will be responsible for bringing the patient to orthodontic appointments?
Dental Insurance
Do you have dental insurance?
Yes
No
Primary policy holder’s full name
Social Security Number
Relationship to patient
Date of Birth
Address (If different than above)
Phone (If different than above)
Employer
Insurance company
Group #
ID #
Do you have dual coverage?
Yes
No
Secondary policy holder’s full name
Social Security Number
Relationship to patient
Date of Birth
Address (if different than above)
Phone (if different than above)
Employer
Does this policy have orthodontic benefits?
Yes
No
Don't Know
Physician
Patient's Physician
Physician's Phone
Patient Health Information
Does your child take antibiotic pre-medication before any dental procedures?
Yes
No
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that your child takes.
Have you noticed any unusual changes in your child’s face or jaws?
Yes
No
Any other physical problems?
Yes
No
Please explain
Medical History
Now or in the past, has your child had: (Check all that apply)
Emotional, sensory or developmental issues?
Birth defects or hereditary problems?
Bone fractures, or major injuries?
Any injuries to face, head, neck?
Arthritis or joint problems?
Cancer, tumor, radiation treatment or chemotherapy?
Endocrine or thyroid problems?
Diabetes or low sugar?
Kidney problems?
Immune system problems?
History of osteoporosis?
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
AIDS or HIV positive?
Hepatitis, jaundice or other liver problems?
Polio, mononucleosis, tuberculosis, pneumonia?
Seizures, fainting spells, neurologic problem?
Mental health disturbance or depression?
History of eating disorder (anorexia, bulimia)?
Frequent headaches or migraines?
High or low blood pressure?
Excessive bleeding or bruising tendency, anemia?
Chest pain, shortness of breath, tire easily, swollen ankles?
Heart defects, heart murmur, rheumatic heart disease?
Angina, arteriosclerosis, stroke or heart attack?
Skin disorder (other than common acne)?
Does your child eat a well-balanced diet?
Vision, hearing, or speech problems?
Frequent ear infections, colds, throat infections?
Asthma, sinus problems, hayfever?
Tonsil or adenoids removed?
Does your child frequently breathe through his/her mouth?
Has your child ever taken intravenous medication for bone disorders or cancer such as bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate)?
Has your child ever taken oral medication for bone disorders such as bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate)?
Has your child had allergies or reactions to any of the following? (check all that apply)
Latex (gloves, balloons)
Metals (jewelry, clothing snaps)
Acrylics
Local anesthetics (novocaine, lidocaine, xylocaine)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin
Other antibiotics
Plant pollens
Animals
Foods
Other substances
Other substances (please explain)
Dental History
Now or in the past, has the patient had: (check all that apply)
Erupting teeth very early or very late?
Primary (baby) teeth removed that were not loose?
Permanent or extra (supernumerary) teeth removed?
Supernumerary (extra) or congenitally missing teeth?
Chipped or injured primary or permanent teeth?
Any sensitive or sore teeth?
Any lost or broken fillings?
Jaw fractures, cysts, infections?
Any teeth treated with root canals or pulpotomies?
Frequent canker sores or cold sores?
History of speech problems or speech therapy?
Difficulty breathing through nose?
Mouth breathing habit or snoring at night?
History of speech problems?
Teeth causing irritation to lip, cheek or gums?
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw muscles or face muscles?
Has your child been treated for “TMJ” or “TMD” problems?
Any broken or missing fillings?
Any serious trouble associated with previous dental treatment?
Has your child ever been diagnosed with gum disease or pyorrhea?
Frequent habit of thumb/finger sucking?
Frequent habit of tongue thrust?
Frequent habit of fingernail biting?
Frequent habit of lip sucking?
How often does your child brush?
How often does your child floss?
Please review your answers before submitting the form.
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