Laidlaw Orthodontics - Health History Form

Patient's Name*

First NameLast Name

Birthday*

Gender*

MaleFemaleIdentify As

Siblings (name and age)

Activities

Patient's Cell (please provide if you would like patient to receive text reminders)

Please enter a valid phone number.

For text reminders please provide cellular provider

School

Primary Responsible Party*

Name*

First NameLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer*

Occupation*

Email*

example@example.com

Phone*

Please enter a valid phone number.

Appointment Reminders*

Email appointment reminderText appointment Reminder

For text reminders please provide cellular provider

Secondary Responsible Party

SpouseMotherFatherOther

Name

Date of Birth

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer

Occupation

Email Address

example@example.com

Phone

Please enter a valid phone number.

Appointment Reminders

Email appointment reminderText appointment Reminder

For text reminders please provide cellular provider

Specify Relationship with Patient

Name

Date of Birth

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer

Occupation

Email Address

example@example.com

Phone

Please enter a valid phone number.

Appointment Reminders

Email appointment reminderText appointment Reminder

For text reminders please provide cellular provider

How Did You Hear About Us?

Whom May We Thank For Referring The Patient To Us?

Primary Dental Insurance Policy Holder's Name

Date of Birth

Employer

Insurance Company

Insurance Group Number

Policy/ID Number

Policy Holder’s Social Security Number

Secondary Dental Insurance Policy Holder's Name

Date of Birth

Employer

Insurance Company

Insurance Group Number

Policy/ID Number

Policy Holder’s Social Security Number

Patient’s Dentist

Last Visit

Visited an orthodontist before?*

YesNo

If yes, please list when and where

Tonsils or adenoids been removed?*

YesNo

If yes, please list when

Experienced jaw joint pain/discomfort?*

YesNo

Have any missing or extra permanent teeth?*

YesNo

Have speech problems?*

YesNo

Gums bleed?*

YesNo

Like their smile?*

YesNo

Tobacco or marijuana use? (history or current)*

YesNo

Has the patient ever had an injury to (select all that apply)*

MouthChinTeethNone

Does the patient currently or ever had any of the following habits (select all that apply)*

Have any profile or facial concerns?*

Snore or have symptoms of sleep apnea?*

YesNo

Have immediate family members who have been diagnosed with sleep apnea?*

YesNo

Currently being treated by a physician*

YesNo

Reason

Physician

Last Visit

Phone

Have allergies/sensitivities to medications or latex?*

YesNo

If yes, please list

ADHD*

YesNo

Anxiety*

YesNo

Autism*

YesNo

Sensory Processing Disorder*

YesNo

Other Executive Functioning Deficiency*

YesNo

Current prescription or over-the-counter medications?*

YesNo

If yes, please list medication and reason for use

Is the patient pregnant or nursing?

YesNoNot Sure

By clicking this box, I hereby acknowledge that I have reviewed the HIPAA Notice of Privacy Practice document

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of the patient’s information pertaining to medical treatment necessary to process any insurance claims. I further authorize the application for benefits on the patient’s behalf for covered services and payment of any benefits to the office. I understand that I am responsible for my amount not covered by insurance.

I understand that appropriate, credit bureau reports may be obtained.

I hereby consent to Laidlaw Orthodontics performing radiology services as ordered and recommended for treatment. I hereby authorize to provide my radiologic studies and related health care information to my dentist or referred professional care provider.

I hereby consent to treatment recommended by Dr. Andrea Laidlaw here at Laidlaw Orthodontics or treatment that is referred by Dr. Andrea Laidlaw to be conducted by other professional care provider.

Signature*

Name*

Date*

Primary Responsible Party

Secondary Responsible Party

Additional Responsible Party

Insurance Information

Patient Medical History

Has the Patient

Has the patient been diagnosed with or have symptoms consistent with

HIPAA Notice

Signature