Patient First Name*
Patient Last Name*
Gender* FemaleMale
Address*
City*
Postal Code*
Email*
Cell
Home Phone
Work Phone
Date of Birth*
Age*
Family Dentist
Emergency Contact
Mother
Mother Day Number
Father
Father Day Number
Dental Insurance YesNo
Primary Insurer:
Group/Policy#
Name of Policy Holder
Certificate/ID#:
Birthdate of Policy Holder
Secondary Insurer:
Group/Policy#:
Certificate/ID#
Reason for Orthodontic Consultation?
Have you had prior orthodontic treatment or evaluation? NoYes
Did your dentist refer you to our office? NoYes
If not, whom may we thank for recommending us?
Are you presently in good health? NoYes
Do you have an artificial joint, heart valve replacement or vascular graft? NoYes
Have you had an illness, operation, or been hospitalized in the last 5 years? NoYes
Have you ever been told that you require antibiotics prior to dental treatment? NoYes
Do you see a dentist for regular preventive care? NoYes
Have you ever had, or currently have, any medical conditions? NoYes
List of medical conditions
Are you taking any medication or non-prescription supplement? NoYes
List of medication
Do you Smoke? NoYes
Latex NoYes
Metals(nickel, etc) NoYes
Medications NoYes
Other
Straight Smiles would like your permission to use images taken of your child to showcase our practice on our website and social media.
DECLARATION I grant full permission for photographs of me/my child to be used onlineI grant only anonymous teeth photographs of me/my child to be used onlineI DO NOT grant permission for photographs of me/my child to be used online
Dr. Scramstad is a GP Dentist Providing Orthodontics only. I understand this and provide consent for examination of myself/ my child. I have read and accepts the Straight Smiles - Privacy Act Information
Patient Signature
Parent Signature (If Patient is a Minor)
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