Patient Information

Patient Name*

Gender

Male

Female

Social Security Number

Birth Date

Drivers License Number

Home Address

City

State

Zip

Primary Phone Number *

Phone type

Home

Cell

Secondary Phone Number

Phone type

Home

Cell

Other

E-mail Address

Employers Name

Occupation

Spouse/Emergency Contact Information

Spouse/Partners Name

Emergency Contact Name

Phone Number

Relation to you

Address

City

State

Zip

Person(s) OK to release appointment or medically related information to concerning you.

Relation

Dental Insurance Information

Primary Insurance Company

Insurance Phone Number

Policy Holders Name

Group Number

Member ID Number

Relationship

Policy Holders Social Security Number

Policy Holders Birth Date

Employer

Secondary Insurance Company

Phone Number

Group Number

Policy Number

Member ID Number

Subscriber Holders Name

Relationship

Policy Holders Social Security Number

Policy Holders Birth Date

Employer

Dental History

General Dentist

Last Visit

Name of person referring (if applicable)

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

Has your child visited an orthodontist before?

Yes

No

When?

Reason?

Has your child's tonsils or adenoids been removed?

Yes

No

Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?

Yes

No

Does your child you have any missing or extra permanent teeth?

Yes

No

Has your child ever had an injury to (select all that apply):

TeethMouthChin

Does your child have speech problems?

Yes

No

If so, explain:

Do your gums bleed?

Yes

No

Do you smoke?

Yes

No

Do you like your smile?

Yes

No

Medical History

Are you currently being treated by a physician?

Yes

No

Reason

Physician

Last Visit

Phone

Do you have any allergies/sensitivities to medications or latex?

Yes

No

If yes, please list allergies:

Are you currently taking any prescription or over-the-counter medications?

Yes

No

Please list, with dosage:

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?

Yes

No

Have you had any serious illnesses or operations? If yes, describe:

Have you ever had a blood transfusion?

Yes

No

(Women)

Are you pregnant?

Taking birth control pills?

Yes

No

Nursing?

Yes

No

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.

Patient Signature and/or Responsible Party

Date

Required field*

Adult New Patient Information