Adult Patient Information

"*" indicates required fields

Patient's Name:*

First Middle Last

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Birthdate*

Age*

Sex Assigned At Birth*

Male

Female

Gender Identity*

Male

Female

Nonbinary

Pronouns*

Who can we thank for your referral?*

Who is your General Dentist?*

What is your chief concern?*

Responsible Party Information

Name*

First Middle Last

Relationship to Patient*

Marital Status*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Home Phone*

Work Phone*

Cell Phone*

Email Address*

How would you prefer to be contacted for appointment reminders*

Text

E-mail

Both

Dental Insurance Information

Do you have dental insurance?

Yes

Insured’s Name*

Relationship to Patient*

Employer*

Member ID #*

Birthdate*

Insurance Co.*

Group #*

Telephone #*

Do you have secondary dental insurance?

Yes

Insured’s Name*

Relationship to Patient*

Employer*

SS or ID #*

Birthdate*

Insurance Co.*

Group #*

Telephone #*

Dental History

When was your last dental checkup/ cleaning?*

Have you ever had a negative dental experience?*

Do you have any missing, impacted teeth, or extra permanent teeth?*

Have you ever visited with an orthodontist before?*

Do you feel that your teeth are too small or short?*

Yes

Do you feel that your teeth are too large or long?*

Yes

Do you feel that your teeth are misshapen?*

Yes

Do you feel that your teeth are too crooked or crowded?*

Yes

Do you feel there is too much or too little gum tissue showing when you smile?*

Yes

Have you ever had any pain, tenderness, or stiffness in your jaw joint (TMJ/TMD)?*

Yes

Do you have any speech problems?*

Yes

Have you ever had any injury to face, mouth, teeth or chin?*

Yes

Airway History

Have you ever worn a CPAP for apnea issues?*

Yes

Are you a restless sleeper?*

Yes

Do you snore at night?*

Yes

Do you sleep walk?*

Yes

Are you a mouth breather?*

Yes

Any issues with bed wetting?*

Yes

Do you clench/grind your teeth?*

Yes

Do you sleep talk?*

Yes

Have you ever worn an Oral Appliance for sleeping, snoring or apnea?*

Yes

Do you have problem concentrating either at home, school or work?*

Yes

Have your tonsils and/or adenoids been removed?*

Tonsils

Adenoids

Both

N/A

When?*

Month Year

Have you ever had ear tubes?*

Yes

When?*

Month Year

Have you ever had a tongue revision?*

Yes

When?*

Month Year

Habits

Sucking your thumb or fingers*

Yes

Lip sucking or biting*

Yes

Thrusting your tongue when swallowing*

Yes

Other oral/mouth habits*

Yes

Medical History

Have you ever had any of the following medical problems listed below?

Artificial joints*

Yes

Fever blisters/Cold Sores*

Yes

Arthritis*

Yes

Hearing impairment*

Yes

Asthma*

Yes

Heart problems*

Yes

Bleeding disorder*

Yes

Hepatitis*

Yes

Blood pressure problems*

Yes

HIV+/AIDS*

Yes

Chemo/Radiation*

Yes

Kidney/Liver defects*

Yes

Chicken pox*

Yes

Mitral valve prolapse*

Yes

Convulsions/Epilepsy*

Yes

Sinus problems*

Yes

Diabetes*

Yes

Back/Neck problems*

Yes

Tuberculosis*

Yes

Seizures*

Yes

Anxiety*

Yes

Depression*

Yes

ADD/ADHD*

Yes

Sensory issues*

Yes

Do you require premedication prior to dental visits?

Yes

Are you currently taking any prescriptions, supplements, or over-the-counter medications?*

Yes

Please list prescriptions, supplements, or over-the-counter medications:*

Have you ever taken bisphosphonate drugs used to treat osteoporosis or multiple myeloma?*

Yes

Have you ever taken medications to strengthen your bones and prevent fractures?*

Yes

Are you pregnant?*

Yes

Week?*

Do you have any allergies to the following?

Aspirin*

Yes

Latex*

Yes

Any metals*

Yes

Penicillin*

Yes

Codeine*

Yes

Tetracycline*

Yes

Dental Anesthetics*

Yes

Erythromycin*

Yes

Other allergies not listed*

Please elaborate on any other medical concerns*

Do you have any specific questions for Dr. Jacob Zitterkopf?*

Tell us what matters most to you.

Please rate each item below on a scale of 1 to 10, 10 being most important

Pain/Discomfort*

Length of Treatment*

Aesthetics of Treatment*

Cost of Treatment*

Quality of Results*

I hereby grant Zitterkopf | Gaworski Orthodontics permission to use photos and videos of me taken during orthodontic treatment for promotional purposes on social media platforms, including but not limited to Facebook, Instagram, TikTok, and YouTube. The visual content may include photographs, videos, or images captured during appointments, progress updates, treatment procedures, and other related activities. These visuals may feature your face, smile, teeth, and orthodontic appliances. The purpose of using these visuals is to showcase the results of orthodontic treatment, educate the public about orthodontic procedures, and raise awareness about the services provided by our clinic. It may also include sharing patient testimonials, with proper anonymity if requested. Your consent allows our clinic to use the visual content for an indefinite period, unless otherwise specified in writing. If you wish to remain anonymous or have specific portions of your visual content obscured, please let us know in writing. You have the right to refuse or modify your consent at any time. If you change your mind regarding the use of your visual content, please notify us in writing, and we will respect your decision promptly.*

Yes

By providing your phone number, you agree to receive text messages from Zitterkopf | Gaworski Orthodontics. Message and data rates may apply. Message frequency varies. I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in strict confidence and it is my responsibility to inform this office of any changes to medical status. I hereby authorize release of any information related to insurance claim. I consent to examination by the doctor and authorize payment of any insurance benefits. I consent that I have reviewed the Notice of Privacy Practices and had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations.

HIPAA and Use of Health Information Policies*

I have read and agree to the HIPAA and Use of Health Information Policies

Signature*

Date*

Jacob G. Zitterkopf DDS, MSD :

Date :

7884137127