ADULT PATIENT INFORMATION
What is your preferred location?
Rockwall
Watauga
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Whom may we thank for referring you to our office?
Patient Name
Preferred name?
State
Sex?
Male
Female
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Zip
Date of birth
Phone
Email
Home Address
Street Address
City
State
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Alabama
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Virginia
Virgin Islands
Vermont
Washington
West Virginia
Wisconsin
Wyoming
Zip
Billing Address (if different from home address)
Address
City
State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Palau
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Virgin Islands
Vermont
Washington
West Virginia
Wisconsin
Wyoming
Zip
HEALTH CARE PROFESSIONAL(S)
Physician Name
Physician Phone
General Dentist Name
General Dentist Phone
DENTAL INSURANCE INFORMATION
Do you have insurance?
Yes
No
Please Choose One
Name of Policy Holder
Policy Holder Date of Birth
Relation to the Patient
Employer
Insurance Company
Insurance Company Phone
Insurance Member ID or SSN
Subscriber Address
City
State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Palau
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Virgin Islands
Vermont
Washington
West Virginia
Wisconsin
Wyoming
Zip
Secondary Insurance?
Yes
No
If yes, please fill out the following:
Name of Secondary Policy Holder
Secondary Policy Holder Date of birth
Relation to the Patient
Secondary Insurance Company
Secondary Insurance Company Phone
Secondary Insurance Member ID or SSN
Secondary Subscriber Address
City
State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Palau
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
West Virginia
Wisconsin
Wyoming
Zip
MEDICAL HISTORY
Are you taking Phospate any medication?
Yes
No
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If yes, please list medication details
Are you allergic to any medication?
Yes
No
Please Choose One
If yes, tell us details about that
Have you ever smoked or chewed tobacco?
Yes
No
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Do you experience sleeping problems such as snoring or sleep apnea?
Yes
No
Please Choose One
If yes, tell us details about that
Select all the medical conditions below that you have had or currently have.
Abnormal bleeding/Hemophilia
Diabetes
Hepatitis/Liver problems
Pneumonia
Arthritis
Epilepsy
High Blood Pressure
Radiation/Chemotherapy
Asthma or Hayfever
Gastrointestinal Disorders
HIV / Aids
Rheumatic Fever
Bone Disorders
Heart Problems
Kidney Problems
Tuberculosis Congenital
Heart Defect
Heart Murmur
Nervous Disorders
Tumor or Cancer
Are there any medical conditions we have not discussed that you feel we should be aware of?
DENTAL HISTORY
What is the main reason for visiting an orthodontist?
Are you presently in any dental pain?
Yes
No
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If yes, please tell us details about that
Have there been any injuries to face, mouth, or teeth?
Yes
No
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If yes, please tell us details about that
Is any part of your mouth sensitive to pressure?
Yes
No
Please Choose One
If yes, please tell us details about that
Do you have any type of thumb or tongue habit?
Yes
No
Please Choose One
If yes, please tell us details about that
Have you ever seen an orthodontist?
Yes
No
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If yes, who and when?
Are you aware of your jaw clicking or popping?
Yes
No
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Have you ever been told that you grind your teeth?
Yes
No
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Are you aware that some appointments will be during work hours?
Yes
No
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Have you ever lost or chipped any teeth?
Yes
No
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Is any part of your mouth sensitive to temperature?
Yes
No
Please Choose One
If yes, where?
Do your gums bleed when you brush?
Yes
No
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Are you a mouth breather?
Yes
No
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Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
Yes
No
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Are you a mouth breather?
Yes
No
Please Choose One
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
Yes
No
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Are you aware of clenching your teeth during the day?
Yes
No
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Have you ever experienced chronic ringing in your ears?
Yes
No
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Any history of speech problems?
Yes
No
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Have had periodontal/gum treatment?
Yes
No
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Is there any other dental condition we should be aware of?
Yes
No
Please Choose One
If yes, please describe
Photo Release Form
I hereby authorize Shaw Orthodontics or any of their assignees to take photographs, slides, and videos of teeth, jaws and face of myself or child. I understand that the photographs, slides, and videos will be used as a record of care and may be used for communication with other health care professionals, educational publications (orthodontic journals), and educational lectures. The content may also be used for advertising purposes (including website publications, social media posts, etc.
I further understand that if the photographs, slides, and videos are used in any publication or as part of a demonstration, identifying information (first name only) could be used.
I do not expect compensation, financial or otherwise, for the use of these photographs.
A photostatic copy of this policy shall be considered as effective and valid as the original. I have read, understand and agree to the terms set forth in the financial policy as indicated by my signature below.
I agree
Photo Refusal Form
I do not authorize Shaw Orthodontics or any of their assignees to use any photographs, slides or videos for advertising purposes (including website publications, social media posts, educational publications and educational lectures.
I understand the photographs, slides and videos will be used only as a record of my care and may be used for communications with other health care professionals.
A photostatic copy of this policy shall be considered as effective and valid as the original. I have read, understand and agree to the terms set forth in the financial policy as indicate by my signature below.
I refuse
Signature
Today's Date