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.
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Employer Information
Spouse Information
Person Responsible for Account
Primary Orthodontic Insurance
Orthodontic Coverage
Secondary Orthodontic Insurance
Orthodontic Coverage
Medical History
Do you have a personal physician
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Please describe your physical health
For Women
Are you currently on a birth control pill?
Are you pregnant?
Are you nursing?
What are the main concerns you would like orthodontics to address?
Have adeniods or tonsils been removed?
Have you been informed of any missing or extra permanent teeth?
Have you ever had any pain or tenderness in the jaw joint (TMJ, TMD)?
Do you brush your teeth daily?
Do you floss your teeth daily?
Have you ever had any of the following medical issues? (It is required you fill each one of these out in order to continue and submit this form).
Abnormal Bleeding *
Allergies to any drugs *
Allergy to latex/metals *
Allergy to plastic *
Any Hospital Stays *
Any Operations? *
Asthma *
Cancer *
Congenital Heart Defect *
Convulsions/Epilepsy *
Diabetes *
Handicaps/Disabilities *
Hearing Impairment *
Heart Murmur *
Hemophilia *
Hepatitis *
HIV + /AIDS *
Kidney / Liver Problems *
Rheumatic / Scarlet Fever *
Tuberculosis (TB) *
Please list an emergency contact not living with you
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.
I Agree to the above terms and conditions *