Date___________________ Patient’s name ____________________________________________________________________ Last First Middle Residence _______________________________________________________________________ Street City Zip Mailing Address ___________________________________________________________________ Street City Zip How long at this address?______ Home phone_______________ Work phone _____________ Cell Phone______________________ Nickname______________________ Birthdate_______________ Social Security # _____________ Sports/Hobbies ___________________________________________________________________ Email Address____________________ Whom may we thank for referring you to our office? _______________________________________ Employer____________________________ Occupation___________ #. years employed ________ Marital Status: Single__ Married__ Widowed__ Separated__ Divorced___ Spouse Information (if applicable):

Spouse’s Name_____________________________ Relationship to Patient ________________ Employer_____________________________________ Occupation____________________ No. years employed _______________________________ Social Security # _________________ Birthdate _____________ Work Phone _____________

EMERGENCY CONTACT INFORMATION

Name of nearest relative not living with you _____________________________________________ Relationship to Patient ______________________________________________________________ Complete address _________________________________________________________________ Street City Zip Home phone_______________ Work phone _____________ Cell Phone______________________

5961 N. Dallas Pkwy.Suite 601Plano, TX 75093Tel: 972-473-3000Fax: 972-473-3001

GUPTA ORTHODONTICSTomorrow’s Orthodontics Today

ADULTPATIENT INFORMATION

MEDICAL HISTORY

Physician __________________________________________ Date of Last Visit _______________________ Address ___________________________________________ Phone ________________________________ Please circle Yes or No (If Yes, please fill in details) Yes No Are you taking any medication? ___________________________________________________ Yes No Are you allergic to any medication? ________________________________________________ Yes No Do you have a history of a major illness? ____________________________________________ Yes No Have you had any operations? ____________________________________________________ Yes No Have you ever been involved in a serious accident? ____________________________________ Yes No Have you ever smoked or chewed tobacco? __________________________________________ Yes No Have seen a physician in the last 12 months? Why? ___________________________________ Female Patients only: Yes No Are you pregnant? ______________________________________________________________

Circle any of the medical conditions below that you have had or currently have. Abnormal bleeding/Hemophilia Diabetes Hepatitis/Liver problems Pneumonia Anemia Dizziness Herpes Prolonged Bleeding Arthritis Epilepsy High Blood Pressure Radiation/Chemotherapy Asthma or Hayfever Gastrointestinal Disorders HIV / Aids Rheumatic Fever Bone Disorders Heart Problems Kidney problems Tuberculosis Congenital Heart Defect Heart Murmur Nervous Disorders Tumor or Cancer Are there any medical conditions we have not discussed that you feel we should be aware of? _________ __________________________________________________________________________________________

DENTAL HISTORY

General Dentist _____________________________________ Date of last visit ________________________ What concerns you most about your teeth? _____________________________________________________ Yes No Are you presently in any dental pain? _______________________________________________ Yes No Have you ever experienced any unfavorable reaction to dentistry? ________________________ Yes No Have your wisdom teeth been removed? ____________________________________________ Yes No Have you ever lost or chipped any teeth? ____________________________________________ Yes No Have there been any injuries to face, mouth, or teeth? __________________________________ Yes No Is any part of your mouth sensitive to temperature? Where? _____________________________ Yes No Is any part of your mouth sensitive to pressure? Where? ________________________________ Yes No Do your gums bleed when you brush? ______________________________________________ Yes No Do you have any type of thumb or tongue habit? ______________________________________ Yes No Are you a mouth breather? _______________________________________________________ Yes No Have you ever seen an orthodontist? If yes, who and when? _____________________________ Yes No What is your attitude toward receiving orthodontic treatment? ____________________________ Yes No Has anyone in your family received orthodontic treatment? ______________________________ How did they feel about the result? _________________________________________________ Yes No Do your teeth or jaws ever feel uncomfortable when you awake in the morning? ______________ Yes No Are you aware of your jaw clicking or popping? ________________________________________ Yes No Are you aware of clenching your teeth during the day? __________________________________ Yes No Have you ever been told that you grind your teeth? ____________________________________ Yes No Do you have “tension” headaches? _________________________________________________ Yes No Have you ever experienced chronic ringing in your ears? ________________________________ Yes No Are you aware that some appointments will be during work hours? ________________________

I understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Deepak K. Gupta to perform a complete orthodontic evaluation.

Signature: __________________________________________________________ Date: _________________

Insured’s Name__________________________ Insured’s Social Security # ___________________

Employer Name ___________________________________________________________________ Insurance Company_____________________ Group No.______________ Local No. ____________ Insurance Co. Address_______________________________________ Phone No. _____________

Do you have dual coverage? Yes_____ No_____ If yes: Insured’s Name__________________________ Insured’s Social Security # ___________________ Employer Name ___________________________________________________________________ Insurance Company_____________________ Group No.______________ Local No. ____________

Insurance Co. Address_______________________________________ Phone No. _____________ IF ORTHODONTIC INSURANCE covers a part of the fee, it may be paid directly to the practice or to the policy holder as arranged. If at any time, there is a change of employment, job status or insurance carrier, whatever part of the account balance not paid directly to the practice by an insurance company must be paid by the Financially Responsible Person. I herby authorize release of any information relating to this claim and authorize payment of insurance benefits directly to Dr. Deepak K. Gupta. Signature: _______________________________________________ Date: ______________

5961 N. Dallas Pkwy.Suite 601Plano, TX 75093Tel: 972-473-3000Fax: 972-473-3001

GUPTA ORTHODONTICSTomorrow’s Orthodontics Today

ORTHODONTICINSURANCE INFORMATION