Initial Consultation Form
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1THOMAS ORTHODONTICS
PRACTICE LIMITED TO
ORTHODONTICS
ROBERT
G.
THOMAS, D.D.S., M.S.
.
ROBERT L.
THOMAS, D.D.S.,
M.S.
INITIAL
CONSULTATION
PATIENT'S NAIVE
DATE
OF
BIRTH
PATIENT'S ADDRESS
PERSON RESPONSIBLE FOB
THIS
ACCOUNT(INSURED)
CITY
STATE
ZIP
CODE
PATIENT'S
PHONE
PATIENT'S
CELL
PHONE
INSURED ADDRESS
MOIV'S
CELL
PHONE
EIVPLOYED
BY
DAD'S CELL PHONE
CITY
STATE
ZIP CODE
BUSINESS PHONE
rs
rHrs
A
sECoND
oPrNroN?
!
ves
[
ruo
REFEFRED
BY:
DENTIST
f]
rnrrrrur
I
DENTAL HISTORY
PHONE:
CHIEF ORAL COMPLAINT
OTHER
E
DENTIST NAME
DATE
OF
LAST DENTAL EXAM
ANy
PREVTOUS
TVAJOR
DENTALTBEATTVENT,
I
VeS
[
ruO
WUeru
DO
YOU HAVE
OR
DO
YOU USE ANY OF
THE
FOLLOWING
-
INDICATE
W
U
E
(
T/
)
I
Teeth sensitive to
cold,
heat, sweets
or
pressure
I
eteeoing gums. How long
I
rooo
lmpaction
I
Ctencning or grinding
I
aurning
of
longue
I
Swelling
or
lumps
in
mouth
!
Frequent blisters
on
lips or mouth
I
eain around
ear
I
Unusual
sounds
in ear
while
eating
I
rv.;.
PHYSICIAN'S
NAIVE
I
Sinus problems
!
Unpleasant taste
fl
Periodontat treatment
fl
Ortnooontlc
treatment
fl
Mouth bleeding
I
Thumb
sucking
!
Fingernail
biting
tr
!
Gag
reftex
MEDICAL
HISTORY
I
Cigarettes, pipe or cigar smoking
l-'l
Texture of toothbrush
!
eao
oreatn
!
Water
let
device
!
Disclosing tablets or solution
I
Fluoride supplements
!
Unfavorable dental
experience
I
Frequency of brushing
!
Complications from
extractions
I
Dental Floss
DATE
OF
LAST PHYSICAL
EXAIVI,
AGE
I
Allergies
to drugs
I
allergies to
anesthetics
I
Any heart
ailments
I
nigr'
blood pressure
I
Neurological problems
I
nadiation
treatments
!
Excessive bleeding
from
cut or extraction
!
Rnemia or blood problems
f]
atooO
translusions
I
Strot<e
I
rnyroio
I
Eye disorders
E
Tonsilljtis
!
Tuberculosis
I
utcer
or colitis
I
Pr"gnancy
lf so,
what
month
I
Venereal disease
DO
YOU HAVE
OR
HAVE
YOU HAD ANY OF
THE
FOLLOWING
-
INDICATE
WITH A
(
V/
)
I
n,tn,itis
I
Hay fever or
allergies
in general
I
oiauetes
!
xianey
problems
I
Liu"r
problems or hepatitis
I
Malignancies
!
Psychiatric care
!
Rheumatic {ever
f]
n"tma
THE
ABOVE
INFORMATION IS NEEDED IN CASE OF
AN
EMERGENCY
Dental insurance
plan
(if any)
Name
of
Carrier
lnsured
Date
of
Birth
Phone
Address
Subscriber
lD
Group
#
Amount of
Ortho
Coverage
INSURANCE: Please
bring
in
your insurance form
at
the beginning of orthodontic treatment for
a
pre-treatment
estimate.
We
will
accept
payment
from insurance companies or directly from you.
Please note
that insurance rarely
if ever
covers your entire bill. Most insurance
companies
pay
quarterly for
braces.
We
will
set
up a payment plan
with
no interest
charge at
the initiation of treatment.
Signature
(parent or guardian, if
palient
is
a
minor)
Date
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