Hughes Orthodontics

Please complete all 4 pages of this form. Thank you!

Gender

Male

Female

Other

Parent / Guardian #1 - Name(optional)

Parent / Guardian #1 - Relationship to Patient

Mother

Father

Guardian

Self

Other

Parent / Guardian #1 - Email

Parent / Guardian #1 - Cell Phone

Parent / Guardian #1 - SSN

Parent / Guardian #1 - Address (if different than child's)(optional)

Have you seen our (please check all that apply):

Website

Google reviews

Google maps listing

Facebook posts

Instagram posts

Sweepstakes

Car Magnets

Gunston Soccer Club sponsorship

I haven't seen any of these things

Parent / Guardian #2 - Name(optional)

Parent / Guardian #2 - Relationship to Patient(optional)

Mother

Father

Guardian

Parent / Guardian #2 - Occupation(optional)

Parent / Guardian #2 - Employer(optional)

Parent / Guardian #2 - Email(optional)

Parent / Guardian #2 - Cell Phone Number(optional)

Parent / Guardian #2 - SSN(optional)

Parent / Guardian #2 - Address (if different than child's)(optional)

Parent / Guardian #2 - Marital Status(optional)

Does the patient have siblings? If so, please tell us about them! If not, skip to the next section.

Sibling #1 - Name(optional)

Sibling #1 - DOB(optional)

Sibling #2 - Name(optional)

Sibling #2 - DOB(optional)

Person Responsible for Account

Parent / Guardian #1

Parent / Guardian #2

Other

If "Other," please fill out the following information. Alternatively, skip to the next section - Dental Insurance.

Responsible Party - Name(optional)

Responsible Party - SSN(optional)

Responsible Party - Email(optional)

Responsible Party - Cell Phone Number(optional)

Responsible Party - Address(optional)

Dental Insurance

Primary Insurance Company Name(optional)

SSN Or Member ID(optional)

Orthodontic Coverage(optional)

Yes

Unsure

Insured's Name(optional)

Insured's DOB(optional)

Photo of Insurance Card - Front & Back Please!(optional)

Choose file

Secondary Insurance Company(optional)

Secondary Insurance - SSN Or Member ID(optional)

Secondary Insurance - Group Number(optional)

Secondary Insurance - Orthodontic Coverage(optional)

Yes

Unsure

Secondary Insurance - Insured's Name(optional)

Secondary Insurance - Insured's DOB(optional)

Secondary Insurance - Photo of Insurance Card (front & back please!)(optional)

Choose file

You are on page 1 of 4, please click Next to continue.

Please answer the below questions on behalf of the patient.

Please tell us if the answer is Yes to any of the below questions:

If the patient has been previously had an orthodontic consult, please tell us who provided the consult:(optional)

Has the patient ever been treated for any of the following? (If yes, please tell us by whom in the other box)

Bad Bite

Periodontal Disease

TMJ

None of the above

Other

What aspect of treatment is the patient most concerned with?

Quality

Cost

Discomfort

Time

Other

You are on page 2 of 4, please click Next to continue.

Is the patient's general health good at this time?

Yes

If no, please explain:(optional)

What is the name of the family physician?

If the patient is currently under the care of a physician, please tell us why: (optional)

If the patient is taking any medication, please list all of them below: (optional)

If the patient is allergic to any medications, please list them all below: (optional)

Has the patient ever had tonsils or adenoids removed? If so, tell us at what age in the other box below

Yes

Other

If the patient has ever had a serious illness or been hospitalized, please elaborate below: (optional)

If the patient has any special problems, please explain below: (optional)

If the patient has ever been advised by their physician to take an antibiotic prior to any dental treatment, please list antibiotic and method below:(optional)

Patient's Approximate Height

Patient's Approximate Weight

Please select any of the below statements that are TRUE:

The patient shown signs of increased growth recently.

The patient has reached puberty.

The patient has started menstruating.

The patient's voice has changed.

None of the above are true.

Has the patient ever had any of the following - now or in the past:

If Hepatitis, please list type:(optional)

Has the patient ever had any of the following - now or in the past:

If Heart Surgery - please list date:(optional)

Has the patient ever had any of the following - now or in the past:

You are on page 3 of 4, please click Next to continue.

Informed Consent

I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION OR INFORMATION NOT DISCLOSED.

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