Please take a minute to fill out the patient information form before your first appointment 1. Tell Us About Your Child/YourselfToday's Date Date Format: MM slash DD slash YYYY Last Name*First Name*Middle NameBirthdate* Date Format: MM slash DD slash YYYY NicknameGender Male Female Address Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code SchoolGradePhone Number*Social Security Number2. General InformationWho is accompanying the patient today?NameDo you have legal custody of this patient? Yes No Whom may we thank for referring you?Other siblings seen by us3. Parent's InformationParents Marital Status Single Married Widowed Divorced Separated Fathers InformationAre you the: Father Step Father Guardian Self NameBirthdate Date Format: MM slash DD slash YYYY Address Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security NumberHome Phone NumberWork Phone NumberExtCell Phone NumberEmailEmployerHow long there?OccupationEmployers Address Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code If you have Dental Insurance Coverage for this Patient, please fill out below:Insurance Co. NameInsurance Address Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Phone NumberGroup # (Policy, Local, or Policy #)Mothers InformationAre you the: Mother Step Mother Guardian Self NameBirthdate Date Format: MM slash DD slash YYYY Address Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security NumberHome Phone NumberWork Phone NumberExtCell Phone NumberEmailEmployerHow long there?OccupationEmployers Address Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code If you have Dental Insurance Coverage for this Patient, please fill out below:Insurance Co. NameInsurance Address Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Phone NumberGroup # (Policy, Local, or Policy #)4. ReleaseType your name to sign (Parent's name if minor)Date of application signature Date Format: MM slash DD slash YYYY Confidential (for record and pretreatment evaluation). I understand that where appropriate, credit bureau reports may be obtained.5. Dental and Medical HistoryDentistPhysician1. Date of last medical examination Date Format: MM slash DD slash YYYY 2. Is patient presently under physician's care? No Yes 3. Is patient presently receiving any medication? No Yes 4. Has patient ever had Rheumatic fever, Diabetes, chronic kidney, heart, lung or liver problems, Epilepsy, Cerebral palsy, comas, Heptitis or AIDS? No Yes If yes, check which one Rheumatic fever Diabetes Chronic Kidney Heart Lung or liver problems Epilepsy Cerebral palsy Comas Heptitis or AIDS 5. Has patient ever had an unusual reaction to any drug such as penicillin or local anesthetics? No Yes 6. Has the patient ever had abnormal bleeding problems? No Yes 7. Are there any other pertinent medical problems? No Yes Date of last dental examination Date Format: MM slash DD slash YYYY 9. Has the patient had any teeth removed by a dentist? No Yes 10. Has the patient had any problems with sore or bleeding gums? No Yes 11. Does the patient brush his/her teeth in the Morning After Lunch Bedtime 12. Has the patient ever received a severe blow on the teeth or jaws? No Yes 13. Did the patient ever suck his/her thumb? No Yes 14. Does the patient bite his/her fingernails? No Yes 15. Does the patient grind his/her teeth at night? No Yes 16. Does the patient breath through his/her mouth? No Yes 17. Is the patient concerned about the appearance of his/her teeth? No Yes 18. Has the patient ever been teased about the appearance of his/her teeth? No Yes 19. Has the patient ever had previous orthodontic consultation and/or treatment? No Yes By whom?20. Has any member of the family had orthodontic treatment? No Yes 21. Has the patient ever had speech therapy? No Yes 22. Who noticed the need for orthodontic treatment? Dentist Patient Parent 23. Does the patient want his/her teeth straightened? No Yes 24. Are you aware that some appointments will infringe on school time? No Yes 6. Growth InformationSiblings NamesAgesAt what age did patient show the greatest increase in height?Boys - Has patient show signs of pubertal development?Girls - Has the patient show signs of pubertal development?Has the patient started her monthly period?At what age?Bailey Orthodontics Social Media ReleaseBailey Orthodontics utilizes Facebook, Instagram, Twitter, YouTube, Google, and other social media platforms for the free exchange of information and customer service as well as marketing. At times, we will take pictures of our various patients during their treatment or other interactions and potentially post them to various social media outlets that we use, as well as to our website. We will not post a picture of your child or yourself without your consent, nor will we use any photos taken and used for confidential patient records. I (name) give my consent to Bailey Orthodontics for myself or child to use pictures or video that include myself or child in their various social media campaigns. By signing, I understand that Bailey Orthodontics may still use pictures of myself or child even after treatment has concluded.Type your name to sign if you give consent of social media releaseDate of Social Media Release Consent Date Format: MM slash DD slash YYYY Do you accept the consent of the social media release? Accept Decline
