Patient Info > Patient Forms

Patient Forms

Save up to 30 minutes at your first visit by completing our online Patient Registration and Health History forms from the convenience of your own home.

 
Personal Information
First Name Middle Name Last Name
Social Security # Date of Birth  
- - - -  
Marital Status Spouse's First Name Spouse's Last Name
yes no
Spouse's Occupation    
   
Home Address
Street City State Zip Code
Contact Info
Home Phone Number Cell Phone E-mail Address
Work Info
Employer Business Phone    
   
Work Address      
Street City State Zip Code
Medical History
Physician's First Name Physician's Last Name Physician's Phone
Date of Last Visit Medical ID Number  
 
Physician's Address      
Street City State Zip Code
Please answer the following questions:
yes
no
  
Have you undergone a physical exam in the past year?
Are you presently under a physician's care?
Have you ever had a major surgery?
Have you ever been hospitalized?
Are you taking any pills, medications or drugs?
Are you allergic to novocain or penicillin?
Have you had any unusual reaction to any medication?
Have you had tonsils and/or adenoids removed?
Do you have fainting or dizzy spells?
Do you have too high or too low blood pressure?
Have you ever been diagnosed or treated for the following?
yes
no
    
yes
no
  
Heart Problems  
Hepatitis
Kidney Problems  
Rheumatic Fever
Lung Problems  
Emotional Problems
Liver Problems  
Malignancies
Allergies  
Endocrine Problems
Diabetes  
Bone Problems
Epilepsy  
Prolonged Bleeding
Anemia  
Tuberculosis
Arthritis  
Asthma
HIV/AIDS  
Hyperactive
 
Dental History
Dentist's First Name Dentist's Last Name Dentist's Phone
Date of Last Cleaning Any Pending Work?
Dentist's Address      
Street City State Zip Code
What is your major concern about your teeth?
Please answer the following questions:
yes
no
  
Have you ever had previous orthodontic consultation or treatment?
Have you been informed of any extra or missing teeth?
Have any permanent teeth been removed by extraction?
Has any family member had orthodontic treatment?
if so who?
Have you ever sucked your thumb or finger?
Do you breath predominantly through the mouth?
Do you have any speech problems?
Do you grind or clench your teeth?
Do you have pain or clicking of the jaw joint?
Have any teeth been injured or chipped due to an accident?
Have you ever had pain in the face or head?
Have you ever had severe jaw or head injury?
Do your gums bleed on brushing or flossing?
Are you concerned about the appearance of your teeth?
Do you want your teeth straightened?
Are there any other dental/orthodontic problems I should be aware of?
Patient Initials Date
 
Insurance Information
Insurance Company Insurance Phone Number    
   
Insurance Address      
Street City State Zip Code
Group Number Local Number    
   
Do you have orthodontic coverage? yes no
If yes, benefit amount:    
If you have secondary insurance
Insured First Name Middle Name Last Name
Social Security # Date of Birth  
- - - -  
Insured's Employer    
 
Insurance Company Insurance Phone Number    
   
Insurance Address      
Street City State Zip Code
Group Number Local Number    
   
Do you have orthodontic coverage? yes no
If yes, benefit amount:    
 
Emergency Information
Name of nearest relative with you
First Name Middle Name Last Name
Complete Address
Street City State Zip Code
Phone Number      
     
Enter the security code:

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Please call us at (310) 444-1113 or send an email to schedule your free initial consultation. We serve Southern California including Los Angeles (LA), Beverly Hills, and Santa Monica.

We look forward to hearing from you!