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

First Name *

Last Name *

Month of Birth *

Day of Birth *

Year of Birth *

Age *

Email address

Best phone number

Address

City

State

Zip Code

Driver's License No.

Social Security No.

Employer

Spouse's Name

Birthdate

Employer

Social Security No.

Driver's License No.

Address (If different from patient)

City (If different from patient)

State (If different from patient)

Zip Code (If different from patient)

Best phone number

Dentist

Address

Phone

Phyisican

Address

Phone

Who may we thank for referring you to our office?

Person Responsible for Account

Medical History

Height

Weight

General Health

Adenoids (removed) *

Yes

Allergies *

Yes

Any Operations *

Yes

Tonsils removed? *

Yes

Blood Disorders *

Yes

Chicken Pox *

Yes

Congenital Heart Defect *

Yes

Diabetes *

Yes

Epilepsy *

Yes

Handicaps/Disabilities *

Yes

Healing Ability (Poor) *

Yes

Heart Disorders *

Yes

HIV + /AIDS *

Yes

Hospitalized for Sickness or Injury *

Yes

Injuries *

Yes

Is Patient Under Treatment at this Time *

Yes

Measles *

Yes

Medication Now Being Taken *

Yes

Mumps *

Yes

Rheumatic / Scarlet Fever *

Yes

X-Ray Treatment (Not Diagnostic) *

Yes

If you have/had any other medical issues not listed above, please describe.

Please describe the problems which concerns you orthodontically

Is patient covered by Dental Insurance

Yes

If yes, by which carrier?

Is patient covered by Secondary Dental Insurance

Yes

If yes, by which carrier?

Has the patient had previous orthodontic consultation or treatment?

Yes

Date:

Doctor's Name

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.

Yes

I Agree to the above terms and conditions *

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