Bracesbycvo.com

Dr. Eric Baugher | Dr. Jennifer Claiborne | Dr. Bruce Bentley7802 Timberlake Road, Lynchburg, VA 24502 434.385.GRIN (4746) | www.bracesbycvo.com Patient’s Last Name: ___________________ First Name: ___________________ Common Name:___________________ Address: ______________________________________________________________________________________ Home #: ____________________________ Cell #: _______________________ Email: ___________________________ Birth Date: ________________ Age: ______ Sex: F / M Grade: _______________ School: __________________________ Hobbies: _________________________________________________________ Referred by: ______________________ Siblings & Age: __________________________________________________________________________________ PARENT OR GUARDIAN INFORMATION (for patients under 18) Parent/Guardian: _______________________ Home #: ______________________ Cell #: ___________________________ Address (if different): ______________________________________________________________________________ Employer: ________________________________________________________ Email: ___________________________ Relationship to Patient: ______________________________________________ Birth Date: ________________________ Parent/Guardian: _______________________ Home #: ______________________ Cell #: ___________________________ Address (if different): ______________________________________________________________________________ Employer: ________________________________________________________ Email: ___________________________ Relationship to Patient: ______________________________________________ Birth Date: ________________________ Has patient ever seen another orthodontist? Y / N Name: _____________ __________ Is this a second opinion? Y / N Patient’s Dentist: ___________________________________________________ Date last seen: ______ Patient’s Physician: ________________________________________________________________________________ Name of other family members seen in our office: __________________________________________________________ What concerns do you have about your/or your child’s teeth? __________________________________________________ Who suggested that you/or your child might need orthodontic treatment? _________________________________________ Person financially responsible for this account: _____________________________ Relationship to patient: _______________ Address (if different): ______________________________________________________________________________ Home #: ____________________________ Cell #: _______________________ Email: ___________________________ SS #: _______________________________ Employer: _______________________ Primary Insured’s Name: ____________________________________________ SS #: ____________________________ Birth Date: ___________________________ Insurance Company: ______________________________________________ Employer: ____________________________ Group #: _____________________ ID #: ___________________________ Primary Insured’s Name: ____________________________________________ SS #: ____________________________ Birth Date: ___________________________ Insurance Company: ______________________________________________ Employer: ____________________________ Group #: _____________________ ID #: ___________________________ Drug or other allergies? List: ______________________________________________________________________________________  Allergies to Latex / Rubber Gloves / Metals / Plastics? (circle which if answer is yes) Has the patient ever taken intravenous bisphosphonates such as Zometa, Aredia or Didronel? Has the patient ever taken oral bisphosphonates such as Fosomax, Actonel, Boniva, Skelid or Didronel? Has the patient ever had problems associated with any previous dental work? Has the patient ever experienced pain, clicking or popping in the jaw joint? Has the patient’s jaw joint ever locked or felt like it was sticking? Has the patient ever had an injury to the mouth/teeth/chin? History of speech problems or speech therapy? Does the patient play a musical instrument? Has the patient ever had any of the following medical issues? I authorize the release of any information regarding my orthodontic treatment to my dental and/or medical insurance company. I certify that the above information is accurate and understand that an appropriate credit bureau report may be obtained. I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental history.
Signature (Patient or Parent/Guardian): ___________________________________ Date: ____________________________

Source: http://www.bracesbycvo.com/sites/all/themes/cvo/docs/27372_Patient_Info.pdf