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Ashland:

wooster:

About.
Services.
First Visit.
Contact.

About.
Services.
First Visit.
Contact.

virtual consultation.

virtual consultation.

patient forms.

"*" indicates required fields

Patient Information

Name*

First Last

Preferred Name/Nickname

Birthday

MM slash DD slash YYYY

Gender*

If patient is a child, who is accompanying them?

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you Own or Rent?*

Own

Rent

Primary Phone Number*

Email*

Who may we thank for referring you to our office?*

Responsible Party Information

*The Responsible Party is the person bringing the patient to their appointment and will be responsible for signing all forms.

Patient is Responsible Party (Skip if checked)

Name

First Last

Birthday

MM slash DD slash YYYY

Social Security #

Relationship to Patient

Occupation

Employer

# Years Employed

Address (if different than the patients)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone Number

Email

Spouse's Name

First Last

Birthday

MM slash DD slash YYYY

Social Security #

Relationship to Patient

Occupation

Employer

# Years Employed

Dental Insurance Information

Check this box if you will be "Self Pay"

Policy Holder Name

First Last

Policy Holder Birthday

MM slash DD slash YYYY

Policy Holder Social Security Number

Policy Holder Employer

Insurance Company Name

ID Number

Group Number

Insurance Company Phone Number

Do you plan to use flex spending or HSA funds?

Yes

No

Do you have dual coverage? (if yes, please fill out Secondary Insurance Information)

Yes

No

Secondary Insurance Information

Insured's Name

First Last

Birthday

MM slash DD slash YYYY

Insured's Social Security Number

Policy Holder Employer

Insurance Company Name

Group Number

Insurance Company Phone Number

Medical History

Physician's Name*

First Last

Date of Last Visit

MM slash DD slash YYYY

Do you have any allergies?

Yes

No

If yes, please list.

Are you taking any medication?

Yes

No

If yes, please list medication.

Are you allergic to any medication?

Yes

No

If yes, please list medication.

Are you currently under the care of a Physician?

Yes

No

If yes, please explain.

Check any of the medical conditions below that you have had or currently have.

Abnormal bleeding/Hemophilia

Anemia

Arthritis

Asthma or Hay Fever

Congenital Heart Defect

Diabetes

Epilepsy

Fever blisters

Heart Murmur

Hepatitis/Liver Problems

High Blood Pressure

HIV/AIDS

Prolonged Bleeding

Radiation/Chemotherapy

Are there any medical conditions we have not discussed that you feel we should be aware of?

Dental History

Dentist Name*

First Last

Date of Last Visit

MM slash DD slash YYYY

What concerns you about your teeth?

Check yes or no: If yes, provide more information.

Are you presently in any dental pain?

Yes

No

Please provide more information:

Have you ever experienced any unfavorable reaction to dentistry?

Yes

No

Please provide more information:

Have you ever sustained injury to your face, mouth, or teeth?

Yes

No

Please provide more information:

Do your gums bleed when you brush?

Yes

No

Please provide more information:

Do you have any type of thumb or tongue habit?

Yes

No

Please provide more information:

Have you previously seen an orthodontist?

Yes

No

If yes, who and when?

What is your attitude toward receiving orthodontic treatment?

Are you aware of your jaw clicking or popping?

Yes

No

Please provide more information:

Have you ever been told that you clench or grind your teeth?

Yes

No

Please provide more information:

Do you have tension headaches?

Yes

No

Please provide more information:

Are you pregnant?

Yes

No

Consent*

I agree to the privacy policy.

Name*

First Last

Date*

MM slash DD slash YYYY

Email

This field is for validation purposes and should be left unchanged.

Ashland: (419) 289-1091

Wooster: (330) 345-3070

info@greggorthodontics.com

© 2022 Gregg Orthodontics