Your first visit with our dentists in Chelsea, Massachusetts, may seem a little overwhelming, but our dentists, Dr. Michael Masse, Dr. Sergey Zemlyanski and Dr. Alfred Griffin, and every member of our team want to make sure that you have a great experience at our office. That experience should begin before you even walk through the door. For your convenience, we have provided our patient forms on this page for you to download and complete at your own pace. You can bring them with you to your visit to Affordable Family Dental, which will allow you to see our team and start creating your new smile sooner. For added convenience, you can submit your forms securely online, which will give our team the chance to review your medical history and begin developing your treatment plan.

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If you have any questions about our patient forms, please call 617-889-2668 and a member of our team will be happy to help.

PATIENT DETAILS
Has the patient been examined by an orthodontist before?
GUARDIAN #1 / INSURANCE INFORMATION

INSURANCE (IF APPLICABLE):

GUARDIAN #2 / INSURANCE INFORMATION
Is there a second guardian and / or additional insurance to add?

ORTHODONTIC INSURANCE (IF APPLICABLE):

SLEEP / AIRWAY ISSUES
Does the patient tend to be a mouthbreather?
Does the patient snore at night?
Does the patient seem rested in the morning?
Is the patient often sleepy during the day?
Has the patient seen an Ear, Nose & Throat Specialist?
Is the patient using a sleep apnea device?
DENTAL/MEDICAL HISTORY

Please check if the patient has a history of the following medical conditions:

Acid Reflux
ADHD/ADD
AIDS/HIV
Anemia
Arthritis
Asthma
Autism
Bone Disorders
Cancer
Cerebral Palsy
Chest Pain
Chronic Neck Pain
Clicking of Jaw
Jaw Pain
Cold Sores/Herpes
Diabetes
Down Syndrome
Endocrine Problems
Emotional Disorders
Epilepsy
Headaches
Heart Condition
Hepatitis
Ear Pain
Immune Problems
Kidney Problems
Low Blood Pressure
Muscular Disorders
Nervous Disorders
Organ Transplant
Osteoporosis
Painful Chewing
Periodontal Problems
Prolonged Bleeding
Rheumatic Fever
Scoliosis
Seizures
Sinus Problems
TMJ Problems
Tuberculosis

Do your gums bleed when you brush?
Is the patient seeing any other dental specialists?
Any dental restorations needing to be completed?
Have there ever been any injuries to the face, mouth or chin?
Have you ever lost or chipped any teeth?
Do you have any pain or soreness around your face, neck or back?
Is any part of your mouth sensitive to temperature or pressure?
Is the patient currently pregnant?
Have adenoids been removed?
Have tonsils been removed?
Currently taking any medications?
Are antibiotics necessary prior to treatment?
Allergies?
Any diseases or problems not mentioned above?

Please check if the patient has, or ever had, any of the following habits?

Cheek, tongue or lip biting
Clenching Teeth
Fingernail Biting
Grinding Teeth
Tongue Sucking
Thumb Sucking
Tongue Thrusting