Tulsa Orthodontists | Patient History | Kirkpatrick & Lai Orthodontics

Name*

First Middle Last

Prefers to be called

Birthdate*

Age*

Hidden

Sex

Sex*

Male
Female

Marital Status*

Home Address*

Street Address Address Line 2 City State ZIP Code

School/Employer*

Grade/Position*

Email

(If over 18)

Home Phone

Work Phone

Cell Phone*

Sibling(s) name(s) and age(s)

How did you hear about our office?*

Dentist
Family Member
Other

Please Specify

Parent / Guardian (if patient under age 18)

Custodial Parent(s) Name(s)

Patient Lives With

(check all that apply)

Mother
Father
Stepmother
Stepfather
Grandparents
Other

Hidden

Do you have contact information for the patient's father/husband?

Yes
No
Not Applicable

Father's Full Name*

First Last

Title

Mr.
Dr.

Marital Status

Home Address

Street Address Address Line 2 City State ZIP Code

School/Employer

Grade/Position

Email Address

Home Phone

Cell Phone

Work Phone

Hidden

Do you have contact information for the patient's mother/wife?

Yes
No
Not Applicable

Mother's Full Name*

First Last

Title

Mrs.
Ms.
Miss

Marital Status

Home Address

Street Address Address Line 2 City State ZIP Code

School/Employer

Grade/Position

Email Address

Home Phone

Cell Phone

Work Phone

Hidden

Siblings: Name & Age

Hidden

Siblings: Name & Age

Hidden

Siblings: Name & Age

Hidden

How did you hear about our office?

Hidden

Responsible Party Email

Hidden

Patient Email (If Over 18)

Account Holder / Billing Information

Responsible Party Full Name*

First Last

Relation to Patient*

Address*

Street Address Address Line 2 City State ZIP Code

Best Contact Phone #*

Hidden

Cell Phone

Do you have dental insurance?*

(if yes, please ask for additional insurance form)

Yes
No

Is the patient on SoonerCare?*

(only applies if under the age of 18)

Yes
No

Signature of Responsible Party*

I certify the above information is true and correct to the best of my knowledge.

First Last

Signature

Patient History

Parent / Guardian (if patient under age 18)

Account Holder / Billing Information

Let's TalkSCHEDULE AN APPOINTMENT!