Pair Orthodontics Valencia

Orthodontics Acquaintance Card

Valencia Office
Patient's Name

First NameLast Name
Age & Sex

AgeSex
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Best Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who may we thank for sending you to our office?
Person Responsible for Account
Email of Responsible Party
Work

OccupationEmployer
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Numbers

Business Phone NumberCell Phone Number
Spouse's Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Spouse's Cell Phone Number

Area CodePhone Number
Work

OccupationEmployer
Spouse's Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Numbers

Business Phone NumberOther Phone Number
IF YOU HAVE ORTHODONTICS INSURANCE, PLEASE COMPLETE INFORMATION BELOW:
DENTAL INSURANCE COMPANY #1
Name of Insurance Company
Their Phone Number

Area CodePhone Number
Group # and ID #

Group NumberID Number
Spouse's Social Security #
This Dental Insurance is provided through:

Name of policy holderRelationship to Child
Date of Birth of the Insurance Holder

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DENTAL INSURANCE COMPANY #2
Name of Insurance Company
Their Phone Number

Area CodePhone Number
Group # and ID #

Group NumberID Number
This Dental Insurance is provided through:

Name of policy holderRelationship to Child
Date of Birth of the Insurance Holder

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dental and Medical History:
Check the box if you have ever had any of the following medical conditions or problems:
Are there any other medical conditions or problems? If Yes, Explain.

Other
Are you currently under the care of a physician? If so, please answer the following:

Name of PhysicianCityTheir Phone Number
ARE YOU ALLERGIC TO ANY MEDICATIONS?
If Yes, please list all allergies separated by a comma.
Are you taking any prescription medication?
If Yes, please list all drugs currently being taken.
DO YOU NEED TO BE PRE-MEDICATED BEFORE DENTAL TREATMENT? If Yes, Explain.

Other
Are you currently under the care of a dentist? If so, please answer the following:

Name of PhysicianThe approx. date of last visit:Their Phone Number
Have there been any injuries to the face, mouth or teeth?
Has you had tongue thrust or speech therapy?
Do you have any speech problems?
Have you ever been informed of any missing or extra teeth?
Does your jaw ever crack or pop sound when chewing or yawning?
Have you ever been told you have TMJ (Temporomandibular Joint) problems?
Are you a mouth breather?
Has your jaw ever locked open?
Has an orthodontist been consulted previously?

Other
When was your last dental care?
Please list your interests, ie. sports, hobbies, etc.
If Yes, please list separated by a comma.
WHAT DO YOU WANT ORTHODONTICS TREATMENT TO ACCOMPLISH?
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest confidence, and it is my responsibility to inform this officeof any changes in my child’s medical status.
Sign below:
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: