Step 1 of 5 20% WELCOME TO CC BRACESADULT’S INFORMATIONPatient’s Legal Name*Gender*MaleFemalePreferred NameDate of Birth* MM DD YYYY Marital Status*SingleMarriedDivorcedWidowedResidence Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How long have you been at this address?*Less than yearMore than 1 yearPrevious Residence Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your mailing address same as residence address?*YesNoMailing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Home PhoneAppointment reminders OK via text*YesNoEmail* Social SecurityWhom may we thank for referring you to our office ?EmploymentEmployerOccupationYears EmployedSpouseSpouse’s Name*Phone*Date of Birth* MM DD YYYY Social SecurityEmployerOccupationYears EmployedIs there anyone have active Duty in Military ?SelfSpouseNoMilitary InformationRank/RateDuty StationRetirement or Rotation Date: MM DD YYYY Insurance InformationPlease allow us to make a copy of your insurance cardDental coverage?*YesNoOrthodontic Coverage?*YesNoDon't knowSubscriber's Name*Name of Policy HolderSubscriber's Date of Birth* MM DD YYYY Member ID or SS#*Employer*Insurance Carrier*Emergency InformationEmergency Contact Name*Name of nearest relative not living with youPhone Number* Personal InformationPatient's Name*AgeMusical Instrument(s) currently playingPersonal Interests or HobbiesName & Ages of ChildrenMedical InformationDental HistoryPatient's Dentist*Last Exam Date MM DD YYYY Is there dental work or gum treatment needed or is progress?*YesNoHave you been to an orthodontist before?*YesNoHave any immediate family members had orthodontic treatment?*YesNoWhat are your main concerns about your teeth?Have you had a serious injury to your face,mouth, or teeth ?*YesNoDo you have missing or extra teeth?*YesNoHave you had a negetive reaction to dental care ?*YesNoDo you have any discomfort when opening/closing your mouth?*YesNoDo you have headaches?*YesNoDo you clench/grind your teeth?*YesNoMedical HistoryDoctor's NameOffice PhoneDate of Last Exam MM DD YYYY Under care of doctor now?YesNoMedications being taken Diseases / AllergiesHave you Experienced* Blood Disorders Drug Allergies Allergy to metals Allergy to latex/plastic Asthma Cancer Epilepsy/Seizures Daibetes Hearing Impaiement Heart Problems Hepetitis HIV/AIDS Kidney/Liver Problems Tuberculosis NONE Other Please specify*Is antibiotic premedication required before dental procedures?*YesNo*Please list any medical problems you have that might have an effect on your treatment in our officeList all medications taking, any additional commentsIf you have ever taken any medications to strengthen your bones, please describe HIPAA PolicyPrivacy Policy* I have clicked on the link above and read the document.PRIVACY POLICY THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.History given by Signature*Date