Patient Information
Westside Orthodontics
Adult New Patient Form
Please bring your Dental Insurance Card to your exam appointment,
or print one off of your insurance company's website.  

Information must be filled out completely

Medical History
Adenoids (removed) *
Allergies *
Any Operations *
Tonsils removed? *
Blood Disorders *
Chicken Pox *
Congenital Heart Defect *
Diabetes *
Epilepsy *
Handicaps/Disabilities *
Healing Ability (Poor) *
Heart Disorders *
HIV + /AIDS *
Hospitalized for Sickness or Injury *
Injuries *
Is Patient Under Treatment at this Time *
Measles *
Medication Now Being Taken *
Mumps *
Rheumatic / Scarlet Fever *
X-Ray Treatment (Not Diagnostic) *
Is patient covered by Dental Insurance
Is patient covered by Secondary Dental Insurance
Has the patient had previous orthodontic consultation or treatment?
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 Agree to the above terms and conditions *