Indian Land Orthodontics
Charlotte Location
Schedule Appointment
803.442.1080
803.442.1080
[email protected]
Charlotte Location
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Patients First Name
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Patient's Last Name
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Birth date
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Gender
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Marital Status
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Home Address
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Phone number
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Email
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May we communicate by phone, email, or text for treatment options and confirming appointments?
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May we discuss your medical condition with any member of your family?
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If yes, please name the members allowed:
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Emergency Contact's Name
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Emergency Contact's Phone Number
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Emergency Contacts relationship to patient
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Patient's Dentist
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Other dentists/dental specialists now being seen
What concerns do you have about your teeth?
Who suggested that you might need orthodontic treatment?
Have you had any previous orthodontic treatment? Please describe.
How did you hear about us?
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Insurance primary policy holder's full name
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Birthdate
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Social security number
Primary policy holder's relationship to patient
Phone number (if not listed previously)
Employer
Insurance company
Group #
ID #
Does this policy have orthodontic benefits?
Yes
No
Don’t know
Have you had any allergies or reactions to any of the following:
Latex (balloons, gloves)
Metals (jewelry, clothing, snaps)
Acrylics
Local anesthetics (Novocain, lidocaine, Xylocaine)
Aspirin
Penicillin
Other antibiotics
Plant pollens
Animals
Foods
Other substances
N/A
Now or in the past, have you had:
Permanent or extra (supernumerary) teeth removed
Supernumerary (extra) or congenitally missing teeth
Chipped or injured primary or permanent teeth
Any sensitive or sore teeth
History of speech problems or speech therapy
Difficulty breathing through nose
Mouth breathing or snoring at night
Frequent oral habits (sucking finger, chewing pen, etc.)
Ringing in ears
Difficulty chewing
Any serious trouble associated with previous dental treatment
Any broken or missing fillings
Bleeding gums, or bad breath
Jaw fractures, cysts, infections
Any teeth treated with root canals or pulpotomies
Gum boils or frequent canker sores/cold sores
Tooth grinding
Tooth clenching
Clicking or locking in jaw joints
Soreness in jaw muscles or face muscles
Teeth causing irritation to lip, gums, or cheek
N/A
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