Orthodontist Patient Forms Bountiful | Bailey Orthodontics

Please take a minute to fill out the patient information form before your first appointment

1. Tell Us About Your Child/Yourself
Today's Date
Date Format: MM slash DD slash YYYY
Last Name*
First Name*
Middle Name
Birthdate*
Date Format: MM slash DD slash YYYY
Nickname
Gender
- Male
- Female
Address
Address City State ZIP Code
School
Grade
Phone Number*
Social Security Number
2. General Information
Who is accompanying the patient today?*
Relation
Do you have legal custody of this patient?
- Yes
- No
Whom may we thank for referring you?
Other siblings seen by us
3. Parent's Information
Parents Marital Status
- Single
- Married
- Widowed
- Divorced
- Separated
Check if you are the Father, Step Father, Guardian, or Self?
- Father
- Step Father
- Guardian
- Self
Name
Birthdate
Date Format: MM slash DD slash YYYY
Address (if different than Patient's)
Address City State ZIP Code
Social Security Number
Home Phone Number
Work Phone Number
Extension Number
Cell/Other Phone Number
Email
Employer
How long there?
Occupation
Employer's Address
Address City State ZIP Code
If you have Dental Insurance Coverage for this Patient, please fill this out below:
Insurance Co. Name
Insurance Address
Address City State ZIP Code
Insurance Phone Number
Group Number (Plan, Local or Policy Number)
Check if you are the Mother, Step Mother, Guardian, Spouse?
- Mother
- Step Mother
- Guardian
- Spouse
Name
Birthdate
Date Format: MM slash DD slash YYYY
Address (if different than Patient's)
Address City State ZIP Code
Social Security Number
Home Phone Number
Work Phone Number
Extension Number
Cell/Other Phone Number
Email
Employer
How long there?
Occupation
Employer's Address
Address City State ZIP Code
If you have Dental Insurance Coverage for this Patient, please fill this out below:
Insurance Co. Name
Insurance Address
Address City State ZIP Code
Insurance Phone Number
Group Number (Plan, Local, or Policy Number)
4. Release
Type 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 History
Dentist
Physician
1. 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 Information
Siblings Names
Ages
At 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 Release
Bailey 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 release
Date of Social Media Release Consent
Date Format: MM slash DD slash YYYY
Do you accept the consent of the social media release?
- Accept
- Decline

Monday	9:00 AM - 5:00 PM
Tuesday	9:00 AM - 5:00 PM
Wednesday	9:00 AM - 5:00 PM
Thursday	9:00 AM - 5:00 PM
Friday	9:00 AM - 12:00 PM
Saturday	Closed
Sunday	Closed

1. Tell Us About Your Child/Yourself

2. General Information

3. Parent's Information

4. Release

5. Dental and Medical History

6. Growth Information

Bailey Orthodontics Social Media Release

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