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Orthodontic Technology
Digital Panoramic X-Rays
iTero® Scanner
Orthodontic Appliances
Herbst Appliance
Orthodontic Elastics
Carriere® Motion Appliance
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Patient lives with whom/relationship
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Name of siblings & ages
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Texas
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Armed Forces Americas
Armed Forces Europe
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State
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Occupation
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Social Security Number
Date of Birth
MM slash DD slash YYYY
Cell Phone
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Primary Insurance Information
Employeer
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Policy ID Number
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Group Number
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Insurance Company Address
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Date of Birth
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Relationship to Patient
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How did you you choose Risinger Orthodontics?
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How did you choose Risinger Orthodontics?
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School Sponsorship
Print Article or Flyer
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Radio
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Event
Family/Friend (fill space below)
Dentist/Doctor (fill space below)
Other (fill space below)
Please Describe:
PLEASE READ
We are passionate about our mission to give everyone a beautiful smile. Please help us to help you and your child by letting us know of any delayed development, social disabilities, ADD or ADHD, Bipolar, Autism, etc.
Medical History
Physician
(Required)
Phone
Date of Last Exam
MM slash DD slash YYYY
Please check all that apply
The patient...
Is currently under medical treatment
Has been hospitalized for any surgical operations or serious illness in the past five years
Is taking medication(s) including non-prescription medicine
Is using tobacco
is allergic medications or substances, including metals
is pregnant
has taken bisphosphonates (ex. Fosamax) for osteoporosis
is allergic to latex
has not reached puberty
Please use this space for any explanation.
Please check all that apply:
Has fever/allergies
Cold sores
Migraines
Diabetes/glaucoma
Rheumatic fever
AIDS or HIV infection
Cardiac pacemaker
Asthma (inhaler)
Fainting/seizures
Thyroid problem
High/low blood pressure
Heart trouble
Epilepsy/convulsions
Removal of Adenoids/tonsils
Leukemia
Kidney/liver disease
Anemia
Cancer
Joint replacement/implant
Hepatitis/jaundice
Stomach troubles/ulcers
Sinus problems
Stroke
Radiation therapy
Respiratory problems
Bone disorder
Osteopenia/osteoporosis
Dental History
Dentist
Date of Last Cleaning
MM slash DD slash YYYY
Please check all that apply.
The patient...
is anxious or nervous about dental treatment
feels pain in their teeth
has sores or lumps in or near the mouth
has had a head, neck or jaw injury
has chronic jaw clicking/popping
clenches or grinds their teeth
bites lips or cheeks frequently
has had speech therapy
has outstanding dental work to be completed
has not had instruction on the correct method of brushing and flossing teeth
bites their nails
sucks their thumb
tongue thrusts while swallowing
breathes through mouth
Please use this space for any explanation.
How many times a day do you brush?
(Required)
Please check the boxes below which describe the problem(s) for which you are seeking treatment:
Crowding
Extra space
Teeth stick out too far
TMJ problems
Poor bite relationship
Missing teeth
Extra permanent teeth
Teeth erupting in the wrong position
Other
If other, please describe
Has the patient had an orthodontic evaluation or treatment before?
(Required)
Yes
No
If so, when and by whom?
Do you have a preference of braces or Invisalign?
(Required)
Authorization and Release
TO THE BEST OF MY KNOWLEDGE THE ABOVE QUESTIONS HAVE BEEN ANSWERED ACCURATELY. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM THIS OFFICE OF ANY CHANGES TO THE PATIENT’S MEDICAL STATUS. I GIVE RISINGER ORTHODONTICS PERMISSION TO PERFORM THE NECESSARY DENTAL SERVICES THAT THE PATIENT MAY NEED.
Consent
By checking this box you agree to the above mentioned consent statement.
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