Greatermadisonorthodontics.com
190500527685048260Specialist in Orthodonticsfor Adults & Children00Specialist in Orthodonticsfor Adults & Children260985048895PATIENT INFORMATION00PATIENT INFORMATION _________________866775224155First MI Last00First MI Last952569850Name: _____________________________________________ Address: _____________________________________City: _________________________ State: ______ Zip: __________ Best Phone: ______________________________Birthday: _____/______/______ Age: ____ Sex: M F Best Email: ______________________________________00Name: _____________________________________________ Address: _____________________________________City: _________________________ State: ______ Zip: __________ Best Phone: ______________________________Birthday: _____/______/______ Age: ____ Sex: M F Best Email: ______________________________________762007239000Whom may we thank for referring you? (Circle)Family Member Family DentistFriend ____________________________ Website2152650128905RESPONSIBLE PARTY INFORMATION00RESPONSIBLE PARTY INFORMATION3552825118110 MOTHER / SPOUSE INFORMATIONName: __________________________________________________Address: ________________________________________________City: ______________________State: _______ Zip: _____________Cell #:______________________Work #:______________________Birthday: ____/____/_______ Marital Status: _______________ SS# ____________________________________________________Employer: _______________________________________________ 00 MOTHER / SPOUSE INFORMATIONName: __________________________________________________Address: ________________________________________________City: ______________________State: _______ Zip: _____________Cell #:______________________Work #:______________________Birthday: ____/____/_______ Marital Status: _______________ SS# ____________________________________________________Employer: _______________________________________________ -66675118110 FATHER / SELF / GUARDIAN INFORMATIONName: __________________________________________________Address: ________________________________________________City: ______________________State: _______ Zip: _____________Cell #:______________________Work #:______________________Birthday: ____/____/_______ Marital Status: _______________ SS# ____________________________________________________Employer: _______________________________________________ 00 FATHER / SELF / GUARDIAN INFORMATIONName: __________________________________________________Address: ________________________________________________City: ______________________State: _______ Zip: _____________Cell #:______________________Work #:______________________Birthday: ____/____/_______ Marital Status: _______________ SS# ____________________________________________________Employer: _______________________________________________ 2152650276860DENTAL INSURANCE INFORMATION00DENTAL INSURANCE INFORMATION-66675238125Subscriber: ___________________________________ DOB: _____/_____/_________ Relationship to Patient: ____________________________Employer:_______________________ Insurance Company: _________________________________ Subscriber ID#:________________________Group #: ________________________________ Local #: ___________________ Phone #: ____________________________________________Address: ____________________________________________________ City: __________________________________ State: ______________ Do you have dual insurance coverage: YES NO If yes, please enter information belowSubscriber: ___________________________________ DOB: _____/_____/_________ Relationship to Patient: ____________________________Employer:_______________________ Insurance Company: _________________________________ Subscriber ID#: _______________________Group #: ________________________________ Local #: ___________________ Phone #: ____________________________________________Address: ____________________________________________________ City: __________________________________ State: ______________00Subscriber: ___________________________________ DOB: _____/_____/_________ Relationship to Patient: ____________________________Employer:_______________________ Insurance Company: _________________________________ Subscriber ID#:________________________Group #: ________________________________ Local #: ___________________ Phone #: ____________________________________________Address: ____________________________________________________ City: __________________________________ State: ______________ Do you have dual insurance coverage: YES NO If yes, please enter information belowSubscriber: ___________________________________ DOB: _____/_____/_________ Relationship to Patient: ____________________________Employer:_______________________ Insurance Company: _________________________________ Subscriber ID#: _______________________Group #: ________________________________ Local #: ___________________ Phone #: ____________________________________________Address: ____________________________________________________ City: __________________________________ State: ______________471106510795677 South Main Street DeForest, WI 53532 (608) 846-360000677 South Main Street DeForest, WI 53532 (608) 846-3600272605536195800 Lincoln AvenueStoughton, WI 53589 (608) 873-788800800 Lincoln AvenueStoughton, WI 53589 (608) 873-7888672465527055520 Medical Circle Madison, WI 53719 (608) 274-5714005520 Medical Circle Madison, WI 53719 (608) 274-5714HEALTH HISTORYPatient’s Name: ____________________________________________________________________________Patient Dentist: __________________________________ Last check up/cleaning: _______________________Patient Physician: ________________________________ Date of Last Physical: _________________________Allergic Reactions (CIRCLE) LatexAspirin Ibuprofen MetalOther: _________________Reaction to allergies_____________________Frequently Experienced (CIRCLE) Headaches Fainting Clenching or Teeth Grinding Gagger Cheek, Tongue or Lip Chewing TMJ Mouth Breather Tongue Thrust Speech Concerns Fever Blisters Finger Nail BitingOther: ______________________________________________________________________________Diagnosed or Treated (CIRCLE) Broken Bones Pregnancy Asthma/Hay Fever Jaundice Hepatitis Diabetes Blood Pressure HIV/Aids Anemia/Hemophilia Epilepsy Drug Addiction Measles Blood Transfusion **Joint Replacement/Implants **Rheumatic Fever/Arthritis **Heart Disease or Mitro Valve Prolapse Radiation or Chemical Therapy Nervous/Emotional Problems Other: _________________________ ** Does the patient require antibiotic pre-medication for dental treatment:YESNOPrescription medications currently taking: (Please list)____________________________Reason: __________________________________________________________________________Reason: ______________________________________________INSURANCE ASSIGNMENT AND RELEASE – I, the undersigned assign directly to Greater Madison Orthodontics all insurance benefits, otherwise payable to me for services rendered. I also hereby authorize Greater Madison Orthodontics to release all information necessary to secure the payment of benefits. I authorize the use of the signature on all insurance submissions. _________________________________________________________________ _________________________________Signature ( Parent or Guardian if patient is a minor)Date ................
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