Come See Us For Your Consultation! No Referral Necessary!

Book An Appointment

Appointment Request

“Take a minute to review, print and fill out our adult information form

before your first visit to save you time on arrival!”

    PATIENT INFORMATION
    Name:
    Date:
    Date Of Birth M/D/Y:
    Age:
    Sex:
    Occupation:
    Home Address:
    City:
    Postal Code:
    Home Tel:
    Daytime Tel:
    Tel Type:
    E-mail address (to confirm appointments):
    Patient’s Dentist:
    Physician:
    Physician Tel:
    Who may we thank for referring you?
    Person Responsible for Account:
    If Person Responsible other than yourself, please indicate relationship
    Do you have an insurance plan that covers orthodontic treatment?
    YesNounsure
    MEDICAL HISTORY
    HAVE YOU BEEN TREATED FOR ANY OF THE FOLLOWING?
    Rheumatic Fever
    YesNo
    Tuberculosis
    YesNo
    Diabetes
    YesNo
    Heart Murmur
    YesNo
    H.I.V./A.I.D.S.
    YesNo
    Kidney Disorder
    YesNo
    Mitral Valve Prolapse
    YesNo
    Hepatitis A, B, or C
    YesNo
    Liver Disease
    YesNo
    Heart Disease
    YesNo
    Sexually Transmitted Diseases
    YesNo
    Asthma
    YesNo
    Artificial Heart Valve
    YesNo
    Blood Disease
    YesNo
    Arthritis
    YesNo
    Artificial Joints
    YesNo
    Prolonged Bleeding
    YesNo
    Other
    If you responded YES to any of the above, please give pertinent information:
    Are you in good health?
    If No please explain
    Do you have any history of major illness and/or operations?
    List any drugs or medication now being taken: Please give reasons:
    Are you currently taking or have you been given intravenous bisphosphonates (such as Zometa or Aredia) for bone cancer?
    YesNo
    Are you currently taking or have you been given oral or intravenous bisphosphonates (such as Fosamax, Actonel, Boniva, Reclast, Skelid, Didronel, or Bonefos) for osteoporosis, osteopenia, or other uses?
    YesNo
    List any allergies or drug sensitivities (Including sensitivity to metals):
    Do you have a tendency to colds?
    Sore Throats?
    Ear Infections?
    Have your tonsils or adenoids been removed?
    If so, at what age?
    (Women) Are you pregnant?
    DENTAL HISTORY
    Have you ever been treated for a jaw joint problem, including surgery?
    YesNo
    Please describe:
    Have there been any injuries to the face, mouth or teeth?
    YesNo
    Please describe:
    Have you ever sucked your thumb or finger?
    YesNo
    Until What age:
    Do you have any speech problems?
    YesNo
    Do you have frequent canker or cold sores?
    YesNo
    Are you a mouth breather? While Asleep:
    YesNo
    While Awake:
    YesNo
    Have you been informed of any missing or extra permanent teeth?
    YesNo
    Have you ever had a previous orthodontic examination?
    YesNo
    Has any other family member had braces or orthodontic treatments?
    YesNo
    If yes, name of family member if treated in our office:
    When did you last see your dentist?
    Reason for orthodontic consultation:

    RELEASE OF INFORMATION: I hereby give Dr. J. Daskalogiannakis and/or members of his staff permission to release information concerning my dental and/or orthodontic health to the family physician, dentist or any other dental specialist as is deemed necessary from time to time. Such information includes x-rays and other diagnostic records pertaining to the initial condition, diagnosis, proposed treatment or treatment in progress.

    Signature:
    Date

    If you’re unable to open PDF files, you can get Adobe Reader® for free.

    Problem retrieving data from Twitter