Ortho Infusion

Name First Last
Date MM / DD / YYYY
Birthdate MM / DD / YYYY
Age
Gender
Male Female
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Cell Number
Phone Carrier
I authorize Norris Orthodontics to me send text messages related to treatment. I understand that standard text messaging rates will apply to any messages received.
Yes No
Home Number
General Dentist
Approximate date of last visit
What concerns you most about your teeth?
Whom may we thank for your visit today?
Is there anyone else in your family that is interested in having a free consultation?
Responsible Party Information

We do respect and protect your privacy.
Parent or Guardian Name First Last
Email
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
How long at address?
Home phone
Work phone
Cell phone
Social Security #
Birthdate MM / DD / YYYY
Relationship to Patient
Employer
Occupation
No. of years employed
Marital Status
Single Married Divorced Other
Spouse's Name
Employer
Occupation
No. of years employed
Social Security #
Birthdate MM / DD / YYYY
Work phone
Dental Insurance Information

If you have dental insurance, please provide the following information so that we can verify your benefits before your scheduled appointment.
Member's Name First Last
Date of Birth MM / DD / YYYY
Members Social Security #
Insurance Company
Phone number
Contract #
Group or local number
Do you have dual coverage?
Yes No
MEDICAL HISTORY
Physician
Date and reason for last visit
Is the patient allergic to latex? (rubber gloves)
Yes No
Please circle Yes or No (If yes, please fill in details)
Are you taking medication?
No Yes
Are you allergic to any medication?
No Yes
Do you have a history of major illness?
No Yes
Do you have a history of cardiovascular illness?
No Yes
Have you ever been involved in a serious accident?
No Yes
Have their been any injuries to the face, mouth, or teeth?
No Yes
Are you presently in any dental pain?
No Yes
Is any part of your mouth sensitive to pressure or temperature?
No Yes
Do your gums bleed when you brush your teeth?
No Yes
Have you ever seen an Orthodontist? If yes, who and when?
No Yes
Do you experience jaw related headaches, clenching of teeth, or TMJ issues?
No Yes
Are there any medical conditions we have not discussed that you feel we should be aware of?
No Yes
BENEFITS

Benefits of Orthodontics: Aesthetics, Health and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums and jaws are an intricate body part and can fail to respond to treatment. An informed consent form will be handed to the responsible party. Please read it carefully and let us answer any questions before the start of treatment. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history.
Name First Last
By typing your name you are agreeing to the above.
Today's Date MM / DD / YYYY
Do Not Fill This Out

Ortho Infusion

Responsible Party Information

Responsible Party Information

Dental Insurance Information

Dental Insurance Information

MEDICAL HISTORY

MEDICAL HISTORY

Please circle Yes or No (If yes, please fill in details)

BENEFITS

BENEFITS