Patient Information
Yao Orthodontics
 New Patient Form
Age of patient *

Information must be filled out completely

Custodial Parent Information
Patient Information
Relationship *
Additional Parent Information
Primary Orthodontic Insurance
Secondary Orthodontic Insurance
What are the main concerns you would like orthodontics to address?
Have adeniods or tonsils been removed?
Have you or your child been informed of any missing or extra permanent teeth?
Have you been informed of any missing or extra permanent teeth?
Has your child ever had any pain or tenderness in the jaw joint (TMJ, TMD)?
Does your child brush his/her teeth daily?
Does your child floss his/her teeth daily?
Is your child currently under the care of a physician?
Are you currently under the care of a physician?
Please describe your child's physical health
Please describe your physical health
Have the patient ever had any of the following medical issues?
Abnormal Bleeding *
Allergies to any drugs *
Allergy to latex/metals *
Allergy to plastic *
Any Hospital Stays *
Any Operations *
Asthma *
Cancer *
Congenital Heart Defect *
Convulsions/Epilepsy *
Diabetes *
Handicaps/Disabilities *
Hearing Impairment *
Heart Murmur *
Hemophilia *
Hepatitis *
Kidney / Liver Problems *
Rheumatic / Scarlet Fever *
Tuberculosis (TB) *
Does the patient have any of the following habits?
Clenching/Grinding Teeth *
Nurse Bottle Habits *
Lip Sucking/Biting *
Speech Problems *
Mouth Breather *
Thumb / Finger Sucking *
Nail Biting *
Tongue Thrust *
Please list an emergency contact not living with you
Agree To Terms
I understand that the information that I have given 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 patient's medical status. I also authorize Yao Orthodontics staff to perform the necessary orthodontic services as needed. I further authorize that photos taken during treatment may be used for professional consultations and are the property of our office. I understand that where appropriate, credit bureau reports may be obtained.
I Agree to the above terms and conditions *