Patient Information

Adult New Patient Form

We would like to welcome you and your child to our office. Our goal is to make everyones visit pleasant, stress free and educational. We pride ourselves in creating beautiful smiles that lasts a lifetime. We look forward to seeing you in the office.

Information must be filled out completely

First Name *

Last Name *

Title *

I prefer to be called

Marital Status *

Month/Day/Year of Birth *

Social Security Number

Email address *

General Dentist *

Date of Last Appointment * +

Who may we thank for referring you to our office? *

Drivers License #

Other Family Members Seen By Us

Home Address

Street Address *

Address Line 2

City *

State *

Zip Code *

Home Phone # *

Cell Phone #

Work Phone #

Employer Information

Employer Name

How Long There?

Occupation *

Best Place to Reach You *

Spouse Information

Name

Month of Birth

Day of Birth

Year of Birth

Work Phone #

Cell Phone

Home Phone

Billing Address

Social Security #

Drivers License #

Employer Name

Person Responsible for Account

Name *

Home Phone *

Work Phone #

Cell Phone

Employer Name

Social Security Number *

Primary Orthodontic Insurance

Orthodontic Coverage *

Yes

No

Policy Holder’s (Parent) First Name

Policy Holder’s (Parent) Last Name

Month/Day/Year of Policy Holder *

Social Security Number

Employer Name

Insurance Company

Insurance Company Address

City/state/zip

Insurance Company Phone #

Group ID Number

Member ID

Relationship to Patient

Secondary Orthodontic Insurance

Orthodontic Coverage *

Yes

No

Policy Holder’s First Name

Policy Holder’s Last Name

Month of Birth

Day of Birth

Year of Birth

Social Security Number

Employer Name

Insurance Company

Insurance Company Address

City/state/zip

Insurance Company Phone #

Group ID Number

Member ID

Relationship to Patient

Medical History

Do you have a personal physician *

Yes

No

Physician Name

Date of Last Visit * +

Please describe your physical health *

Excellent

Good

Fair

Poor

Please list all medications that you are currently taking and for what conditions

Please list any medications that you are currently allergic to.

For Women

Are you currently on a birth control pill? *

Yes

No

Are you pregnant? *

Yes

No

If yes how many weeks?

Are you nursing? *

Yes

No

What are the main concerns you would like orthodontics to address?

Patient

Dentist

Has you ever had or been evaluated for orthodontic treatment before? *

Have there been any injuries to the face, teeth, jaw, mouth or chin? Please explain *

Have adenoids or tonsils been removed? *

Yes

No

Have you been informed of any missing or extra permanent teeth? *

Yes

No

If yes, which ones?

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

Yes

No

Do you brush your teeth daily? *

Yes

No

Do you floss your teeth daily? *

Yes

No

Have you ever had any of the following medical issues?

Abnormal Bleeding *

Yes

No

Allergies to any drugs *

Yes

No

Allergy to latex/metals *

Yes

No

Allergy to plastic *

Yes

No

Any Hospital Stays *

Yes

No

Any Operations *

Yes

No

Asthma *

Yes

No

Cancer *

Yes

No

Congenital Heart Defect *

Yes

No

Convulsions/Epilepsy *

Yes

No

Diabetes *

Yes

No

Handicaps/Disabilities *

Yes

No

Hearing Impairment *

Yes

No

Heart Murmur *

Yes

No

Hemophilia *

Yes

No

Hepatitis *

Yes

No

HIV + /AIDS *

Yes

No

Kidney / Liver Problems *

Yes

No

Rheumatic / Scarlet Fever *

Yes

No

Tuberculosis (TB) *

Yes

No

Do you have any of the following habits?

Clenching/Grinding Teeth *

Yes

No

Speech Problems *

Yes

No

Mouth Breather *

Yes

No

Nail Biting *

Yes

No

Please list an emergency contact not living with you

Name *

Phone *

Address *

City, State, Zip *

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 the dental staff to perform the necessary orthodontic services as needed. I further authorize that photos taken during treatment may be used in journal articles or promotional materials and are the property of our office. I understand that where appropriate, credit bureau reports may be obtained.

Yes

I Agree to the above terms and conditions *

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