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Why Us?
Clear Aligners
Invisalign
How Invisalign Works
Invisalign for Teens
Invisalign for Adults
Spark Clear Aligners
Spark Clear Aligners Case Study
Braces
Braces for Adults
Braces for Teens
Other Treatments
Gummy Smile (Gingivectomy)
Retainers for a Lifetime
New Patients
Blog
Contact Us
Orthofi Patient Login
Orthodontist · Rockford & Grand Rapids, MI
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Please add the name(s) of the person(s) we are authorized to release appointment and medically-related information to:
Authorized person's name
Relation to you
Would you like to add an additional authorized person?
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Authorized person's name
Relation to you
Insurance Information
Do you have insurance?
*
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Primary Insurance Information
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Member ID Number
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Relation
Policy Holder's Social Security Number
Policy Holder's Birthdate
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Work Phone Number
Copay (if known)
Deductible (if known)
Do you have secondary insurance?
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Secondary Insurance Information
Secondary Insurance Company
Phone Number
Group Number
Policy Number
Member ID Number
Policy Holder's Name
Relation
Policy Holder's Social Security Number
Policy Holder's Birthdate
Employer
Work Phone Number
Copay (if known)
Deductible (if known)
Dental History
General Dentist Name
Date of Last Visit
Have you visited an orthodontist before?
Yes
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When?
For what reason?
What are your main orthodontic concerns?
How did you hear about our practice?
Ad
Internet
Family / Friend
Physician
Other
Name of person referring (if applicable)
Have your tonsils or adenoids been removed?
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No
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Yes
No
Do you have any missing or extra permanent teeth?
Yes
No
Have you ever had an injury to (select all that apply):
Teeth
Mouth
Chin
Do your gums bleed?
Yes
No
Do you have speech problems?
Yes
No
Tell us about your speech problem
Do you smoke?
Yes
No
Do you like your smile?
Yes
No
Do you currently or have you ever had any of the following habits?
Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail biting
Thumb/Finger Sucking
Chewing/Eating Problems
Medical History
Are you currently being treated by a physician?
Yes
No
Reason
Physician's Name
Date of Last Visit
Physician's Phone Number
Do you have any allergies/sensitivities to medications or latex?
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No
If yes, please list all allergies
Are you currently taking any prescription or over-the-counter medications?
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No
If yes, please list with dosages
Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Yes
No
Have you had any serious illnesses or operations?
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No
If yes, please describe
Have you ever had a blood transfusion?
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No
If yes, please list approximate dates
Are you pregnant? (Women)
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No
Nursing?
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Taking birth control pills?
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Check if you have or have ever had any of the following:
Abnormal Bleeding
Anemia
Arthritis/Rheumatism
Artificial Heart Valves
Artificial Joints
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Blood Disease
Blood Transfusion
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Cortisone Treatments
Cough, Persistent
Coughing Blood
Diabetes
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Fever Blisters/Herpes
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Heart Problems
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Hospitalized for Any Reason
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Liver Disease
Mitral Valve Prolapse
Pacemaker
Psychiatric Problems
Radiation Treatment
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Sinus Problems
Skin Rash
Stroke
Swelling of Feet or Ankles
Thyroid Problems
Tobacco Habit
Tonsillitis
Tuberculosis
Ulcer
Venereal Disease
Authorization
Authorization
*
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.
Patient Signature and/or Responsible Party
*
Today's Date
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