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Marital Status

Additional Contact Information (e.g. Step Parent)
Additional Contact Information

Your insurance benefits are a contract between you and your carrier. However, with your permission, we would be happy to assist you in obtaining your benefits. Please complete the following as completely as you can, so we can be as helpful as possible.

Additional Information


Have you been a patient in a hospital during the past 2 years?
Have you been under the care of a physician during the past 2 years?
Have you taken any kind of medicine or drugs during the past 2 years?
Are you allergic to Penicillin(s)?
Are you allergic to any other medications?
Do you have a latex allergy?
Have you had any excessive bleeding requiring special treatment?
Do you have any allergies / sensitivities
Have you taken any bisphosphonates or osteoporosis / bone cancer meds. within last 5 years?
Do you smoke?
Women: Are you pregnant?
Is there a possibility that you are pregnant?
>>> Are you nursing?
Do you have ADD?
>>> ADHD?
>>> Any part of the Autism spectrum?
Have you ever tested HIV positive?
Do you snore?
Have you been told that you stop breathing when you are sleeping?
Do you suffer from frequent or severe headaches?
>>> Back pain?
>>> Neck pain?
Do you have any other health history or Medical Conditions we did not ask about?

The above medical history is accurate and current to the best of my knowledge. I understand I need to notify this office whenever there is a change in my health history.

Your "Smiles" Questionaire
Have you ever had an injury to your face, neck or jaws?
Do you have difficulty in opening your mouth wide?
Jaws ever click or pop?
Do you have pain in front of the ears?
Do you have any pre-existing T.M.J. problems?
Check habits
Nail Biting
Lip Biting
Pencil Biting
Night Grinding
Have you ever had any difficulty with past dental treatment?
Do you feel that your teeth are...
Too small or short?
Crooked or crowded?
Too large or too long?
Misshaped (uneven Pointed)?
Off Color?
Do you feel your teeth 'stick out too much' ('buck teeth')?
Are there spaces between your teeth that you do not like?
Does too much gum tissue show when you smile?
Does too little gum tissue show when you smile?
Have you had previous orthodontic treatment (including braces or other appliances?)
Are there other dental issues not listed above that you would like to discuss or have treated?