Phillips Family Orthodontics
Encinitas
Mira Mesa
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Menu
ABOUT
About Us
Meet Dr. Phillips
Locations
Mira Mesa
Encinitas
Our Technology
SERVICES
Braces
Invisalign
Early Treatment
Sleep Apnea Treatment
TMD and Nightguards
Surgical Orthodontics
Laser Gingevectomy and Frenectomy
Retainers
Palatal Expansion
PATIENTS
Consultations
Insurance & Financing
New Patient Form
Smile Gallery
CONTACT US
ABOUT
About Us
Meet Dr. Phillips
Locations
Mira Mesa
Encinitas
Our Technology
SERVICES
Braces
Invisalign
Early Treatment
Sleep Apnea Treatment
TMD and Nightguards
Surgical Orthodontics
Laser Gingevectomy and Frenectomy
Retainers
Palatal Expansion
PATIENTS
Consultations
Insurance & Financing
New Patient Form
Smile Gallery
CONTACT US
Menu
ABOUT
About Us
Meet Dr. Phillips
Locations
Mira Mesa
Encinitas
Our Technology
SERVICES
Braces
Invisalign
Early Treatment
Sleep Apnea Treatment
TMD and Nightguards
Surgical Orthodontics
Laser Gingevectomy and Frenectomy
Retainers
Palatal Expansion
PATIENTS
Consultations
Insurance & Financing
New Patient Form
Smile Gallery
CONTACT US
Patient Information Form
Patient Information Form
Please assist us by completing the following:
Patient's First Name
(Required)
Patient's Last Name
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Age
Sex
Phone
Mailing Address
School Attend If Applicable
Grade
Medical Physician
Patient’s Dentist
Referred by
Name & ages of family members treated by our office
Person responsible for account
Address
City
Zip
Contact E-mail Address
Do you have an insurance plan which covers orthodontic treatment?
Yes
No
Name of insurance company
Father’s Name
ID #
DOB
MM slash DD slash YYYY
Occupation
Employed By
Cell
Mother's Name
ID
DOB
MM slash DD slash YYYY
Occupation
Employed By
Cell
Medical History
Is the patient in good health?
Yes
No
Does the patient have history of major illnesses?
Yes
No
Tick any of the following for which the patient has been treated
(Required)
Diabetes
Bone Disorders
Epilepsy
Prolonged Bleeding
HIV
Pneumonia
Hepatitis
Asthma
Liver Involvement
Osteoporosis
Heart Trouble
Tuberculosis
Kidney Involvement
Fainting & Dizziness
Snoring
Rheumatic Fever
Anemia
Endocrine or Thyroid
Nervous Disorders
Teeth Grinding
List any drugs or medications currently being taken & why:
List any allergies or drug sensitivities
Have tonsils and adenoids been removed?
Yes
No
At what age?
Has the patient experienced significant growth within the last six months?
Yes
No
Dental History
Have there been any injuries to the face, mouth or teeth?
Yes
No
Has the patient every sucked a thumb or finger?
Yes
No
until what age?
Does the patient have any speech problems?
Yes
No
Has the patient had any clicking or discomfort in jaw joints near ears?
Yes
No
Has the patient been informed of any missing or extra permanent teeth?
Yes
No
Has either parent or other children had orthodontic treatment?
Yes
No
Is the patient especially apprehensive toward dental visits?
Yes
No
Does the patient want orthodontic treatment?
Yes
No
Does the patient have any congenital abnormalities?
Yes
No
When did the patient last visit his/her dentist?
Were x-rays taken?
Yes
No
Has the patient had a previous orthodontic examination?
Yes
No
how long ago?
List sports and interests
Reason for today’s visit
Parent (Guardian) Signature
Date
MM slash DD slash YYYY
Dr Phillips Signature
Date
MM slash DD slash YYYY
Hipaa Compliant
I agree to
terms & conditions
provided by the company. By providing my phone number, I agree to receive text messages from the business.
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Call or Text Us Now
New Patients:
(858) 330-5981
Current Patients:
(760) 943-7770
Call or Text Us Now
New Patients:
(858) 330-5981
Current Patients:
(858) 578-1822
