New Patient Information
Gender at birth

Please rank in order of importance your priority in choosing an orthodontic office. Please use each number only once (1 being the most important and 3 being least important).
Optimal orthodontic care and service:
Convenience / location of office:
Lowest cost for orthodontic care:

In case of emergency, contact:
Is the patient a minor?
Who is financially responsible for the account?

Parent 1/Guardian 1 Information
Parent 2/Guardian 2 Information
Patient lives with:
Who will be responsible for bringing the patient to their orthodontic appointments?
Orthodontic Insurance Information
If you have orthodontic coverage, the following information is required for submitting an insurance claim. Please complete the entire section to ensure proper billing. Thank you.
Does this policy have orthodontic benefits?
Does the patient have dual coverage? if yes, please complete the following insurance info:
Financial Responsibility
General Information
Is the patient currently having dental work completed?
Is the patient currently under medical treatment?
Medical Information
The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examination in our office. In order to thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you.
Is, Has or Does the patient...
allergic to latex?
take antibiotic premedication prior to any dental procedures?
in general good health at this time?
had any adverse response to any drugs, including penicillin?
allergic to any known materials resulting in hives, asthma, eczema, etc.?
ever had any major operations including hip/joint replacement?
have any wounds healed slowly or presented other complications?
ever had any radiation therapy or chemotherapy?
ever had a serious accident involving facial and/or head injuries?

Does the patient have or has he/she ever had:
AIDS OR HIV POSITIVE
DIZZINESS
HERPES
ALCOHOLISM
DRUG ABUSE
IMMUNE SYSTEM PROBLEMS
ARTHRITIS OR PAINFUL JOINTS
EMOTIONAL PROBLEMS
INFECTIOUS DISEASE
ASTHMA
EPILEPSY
MIGRAINE HEADACHES
BLOOD DISEASE
EXCESSIVE BLEEDING
RESPIRATORY PROBLEMS
BONE DISORDER
FAINTING
RHEUMATIC FEVER
CANCER
HAY FEVER
SEXUALLY TRANSMITTED DISEASE
CARDIOVASCULAR DISEASE
HEARING DISORDER
SINUS PROBLEMS
CONVULSIONS
HEART MURMUR
TONSILLITIS
DIABETES
HEPATITIS OR LIVER DISEASE
TUMOR OR GROWTH
Other
Does the patient snore?
Does the patient have unexplained awakenings from sleep?
Does the patient, or has the patient been told that you stop breathing for short periods during sleep?
Does the patient get excessively tired during the day and/or fall asleep when you should be awake?
Is the patient on a diet at this time?
Is the patient pregnant?
Has the patient ever smoked or used tobacco products?
Dental History
The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examination in our office. To thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you.
Does the patient's gums bleed?
Has the patient ever had gum disease, or periodontal treatment?
Does the patient frequently get sore spots in their mouth?
Does the patient have any dental complaints at the present time?
Does the patient experience frequent headaches?
Does the patient have a history of back or neck injuries? whiplash?
Does the patient have any clicking or popping of their jaw (tmj)?
Does the patient have pain in or around their ears?
Does any part of the patient's mouth hurt when clenched?
Does the patient habitually clench or grind their teeth during the night or day?
Does the patient have any history of lip sucking or biting?
Does the patient have any history of nail biting?
Does the patient have any history of thumb or finger sucking?
Does the patient have any history of tongue thrusting?
Does the patient have any history of speech difficulty or speech therapy?
Is the patient a mouth breather?
Does the patient chew on only one side of their mouth?
Are any parts of the patient's mouth sore to pressure or irritants (cold, sweets, etc )?
Has the patient ever taken any appetite suppressants (fen-phen, dexfenfluramine, fenfluramine or other)?
Has the patient ever taken medication for treatment of osteoporosis?
Has the patient ever had any poor dental experiences in the past?
Supplemental Informed Consent
Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as "Coronavirus," at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.
Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant. "Social Distancing" nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, orthodontist, orthodontic staff and sometimes other patients at all times.
Although exposure is unlikely, do you accept the risk and consent to treatment?
Release and Waiver (HIPAA)
I authorize the dentist to release any information including the diagnosis and the records of any treatment or examinations rendered to my child during the period of such orthodontic care to third party payers and/ or health practitioners. I understand that my dental insurance carrier may pay less than the actual bill for services, and I am responsible for any benefit not paid by insurance or difference in cost due to lapse in coverage. I agree to be responsible for payment of all services rendered on my child's behalf. I understand that providing incorrect information can be dangerous to my child's health. I will not hold my orthodontist or any member of his 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 child's medical or dental health. I understand that the initial exam with Dr. Zuch is of no charge, and any succeeding services such as pretreatment diagnostics are rendered at additional cost. I have read/reviewed The Tooth Mover's complete HIPAA policy at http://www.mytoothmover.com.
By signing this form, you will consent to our use and disclosure of your protected health information to communicate with your other healthcare providers and insurance company, carry out treatment, payment activities, and healthcare operations.