WELCOME TO OUR OFFICE

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Patient Information...

Which location would you prefer?

 Los Altos San Jose
First Name:
Last Name:
Nickname (if preferred):
Gender:  Male Female
Home Phone:
Cell Phone:
Patient's Birthdate:
Social Security #:
Email:
General Dentist:
Home Address:
Employer:
Occupation:
How Long?
 
Employer Address:
How did you hear about our office?
Have we treated another member of your family?  Yes No
If YES, Name:
What are the main concerns that you would like orthodontics to accomplish?
Have you visited an orthodontist before?  Yes No
If YES, for what reason?
Anything you would like to discuss with the doctor in private?  Yes No

Insurance Information...

Marital Status:  Single Married Widowed Divorced Separated Domestic Partner
 

Primary

Insurance Co. Name:
Insurance Co. Phone:
Insurance Co. Address:
Group or Plan:
Insured's Name:
Insured's Birthdate:
Relationship:
Insured's SS#:
Insured's Employer:
Employer's Address:

Secondary

Insurance Co. Name:
Insurance Co. Phone:
Insurance Co. Address:
Group or Plan:
Insured's Name:
Insured's Birthdate:
Relationship:
Insured's SS#:
Insured's Employer:
Employer's Address:

Dental and Medical History...

Are you currently under the care of a physician?  Yes No
If YES, for what reason?
Physician:
Phone#:
History of major illness?  Yes No
If YES, please describe:
Any sensitivities or allergies?  Yes No
If YES, please describe:
Currently taking any medications?  Yes No
If YES, please describe:
Amount/Dose:
Have you ever been treated for any of the following?  Arthritis Asthma Blood disorder Cancer Diabetes Epilepsy Heart Condition Nervous Disorder Tuberculosis High Blood Pressure
Do you require antibiotics before dental treatment?  Yes No
If YES, explain:
Have there ever been injuries to your face, mouth or chin?  Yes No
Have you ever had pain/tenderness in your jaw joint (TMJ/TMD)?  Yes No
Do/Did you have any of the following habits?  Grinding Teeth Chronic Mouth Breathing Finger/Thumb Sucking Speech Problems Tongue Thrusting Chewing/Eating Problems
Please agree to the following...  (required) - I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child’s medical status. I hereby authorize release of any information related to insurance claim. I consent to examination by the doctor and I authorize payment of any insurance benefits to the office.

OUR LOCATIONS:

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Los Altos Orthodontics:
86 Third Street, Suite 112
Los Altos, CA 94022

1-650-948-3994

Hours:

  • Mon 8:00 – 5:00
    (by apt only)
  • Tues 8:00 – 5:00
    (11:30 – 1:30 lunch)
  • Wed 8:00 – 5:00
    (11:30 – 1:30 lunch)
  • Thurs 8:00 – 5:00
    (11:30 – 1:30 lunch)
  • Fri 8:00 – 5:00
    (11:30 – 1:30 lunch)

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San Jose Orthodontics:

6128 Camino Verde Dr
San Jose, CA 95119

1-408-225-6660

Hours:

  • Mon 8:00 – 5:00
    (11:00 – 1:00 lunch)
  • Tues 9:00 – 4:00
    (by apt only)
  • Wed 9:00 – 5:00
    (12:00 – 2:00 lunch)
  • Thurs 8:00 – 5:00
    (12:00 – 2:00 lunch)