Online Forms- McCaffrey Orthodontics

Online Patient Forms
Patient Details
Name*

Patient's First NamePatient's Last Name
Nickname
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*
Home Phone
Format: (000) 000-0000.
Date of birth*

MonthDayYear
Date
Age*
Race*
Cell Phone
Format: (000) 000-0000.
School/Employer
Grade/position
Work phone
Format: (000) 000-0000.
How did you hear about our office*
Email
example@example.com
Family members treated in our office
Reason for Consultation*
Previous Dentist*
Date of last cleaning

MonthDayYear
Date
Has the patient been examined by an orthodontist before?

YesNo
Guardian #1 / Insurance Information
SelfSpouseFatherMotherStepparentOther (specify)
Guardian's Name*

Guardian's First NameGuardian's Last Name
Home Phone
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer*
Work Phone
Format: (000) 000-0000.
Cell Phone*
Format: (000) 000-0000.
Date of birth*

MonthDayYear
Social Security Number*
Guardian's E-Mail*
Insurance (If Applicable):
Company Name
Phone
Format: (000) 000-0000.
Subscriber/Member ID
Guardian #2 / Insurance Information
Is there a second guardian and / or additional insurance to add?*

YesNo
SelfSpouseFatherMotherStepparentOther (specify)
Guardian's Name

Guardian's First NameGuardian's Last Name
Home Phone
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Work Phone
Format: (000) 000-0000.
Date of birth

MonthDayYear
Social Security Number
Cell Phone
Format: (000) 000-0000.
Guardian's E-Mail
Orthodontic Insurance (If Applicable):
Company Name
Phone
Format: (000) 000-0000.
Subscriber/Member ID

Sleep / Airway Issues

Rows	Yes	No
Does the patient tend to be a mouthbreather?
Does the patient snore at night?
Does the patient seem rested in the morning?
Is the patient often sleepy during the day?
Has the patient seen an Ear, Nose & Throat Specialist?
Is the patient using a sleep apnea device?

Dental/medical History

Please check if the patient has a history of the following medical conditions:

Rows	Yes	No
Acid Reflux
ADHD/ADD
AIDS/HIV
Anemia
Arthritis
Asthma
Autism
Bone Disorders
Cancer
Cerebral Palsy
Chest Pain
Chronic Neck Pain
Clicking of Jaw
Jaw Pain
Cold Sores/Herpes
Diabetes
Down Syndrome
Rheumatic Fever
Scoliosis
Tuberculosis

Please check if the patient has a history of the following medical conditions:

Rows	Yes	No
Endocrine Problems
Emotional Disorders
Epilepsy
Headaches
Heart Condition
Hepatitis
Ear Pain
Immune Problems
Kidney Problems
Low Blood Pressure
Muscular Disorders
Nervous Disorders
Organ Transplant
Osteoporosis
Painful Chewing
Periodontal Problems
Prolonged Bleeding
Seizures
Sinus Problems
TMJ Problems

Do your gums bleed when you brush?

YesNo
Is the patient seeing any other dental specialists?

YesNo
Any dental restorations needing to be completed?

YesNo
Have there ever been any injuries to the face, mouth or chin?

YesNo
Have you ever lost or chipped any teeth?

YesNo
Do you have any pain or soreness around your face, neck or back?

YesNo
Is any part of your mouth sensitive to temperature or pressure?

YesNo
Is the patient currently pregnant?

YesNo
Have adenoids been removed?

YesNo
Have tonsils been removed?

YesNo
Currently taking any medications?

YesNo
Are antibiotics necessary prior to treatment?

YesNo
Allergies?

YesNo
Any diseases or problems not mentioned above?

YesNo

Please check if the patient has, or ever had, any of the following habits?

Rows	Yes	No
Cheek, tongue or lip biting
Clenching Teeth
Fingernail Biting
Grinding Teeth
Tongue Sucking
Thumb Sucking
Tongue Thrusting

Signed Consent
I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status.

I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate orthodontic treatment on the above-named patient.

I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.
Typed Name/Signature*
Relationship to Patient*
Date

MonthDayYear
If someone other than the parent(s) or guardian(s) listed above will be bringing the patient to appointments, please list here:
By submitting this form you agree to the above mentioned consent statement
Should be Empty:

Online Patient Forms

Patient Details

Guardian #1 / Insurance Information

Guardian #2 / Insurance Information

Dental/medical History

Signed Consent