Welcome to the Orthodontist

ADULT PATIENT INFORMATION
Date

MonthDayYear
Date
Patient's Name*

LastFirstMI
Birthdate

MonthDayYear
Age
MaleFemale
Residence:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone #:

Area CodePhone Number
Cell Phone #:

Area CodePhone Number
Cell Phone Provider
Employer:
Occupation:
Social Security #:
E-mail*
Marital Status:

MarriedSingleDivorcedSeparatedWidowedPartnered
Whom may we thank for referring you to our office?
SPOUSE INFORMATION
SPOUSE'S NAME:

First NameMiddle NameLast Name
Birthdate

MonthDayYear
Age:
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone #

Area CodePhone Number
Work Phone #

Area CodePhone Number
Cell #

Area CodePhone Number
Social Security #
E-mail*
example@example.com
DENTAL INSURANCE INFORMATION
Do you have orthodontic coverage? (If no, skip to next section)

YesNo
PRIMARY ORTHODONTIC INSURANCE
Insured's Name:
Birthdate

MonthDayYear
Insurance Company Name
Insurance Company Phone #

Area CodePhone Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Group #:
ID #:
Do you have dual coverage?

YesNo
SECONDARY ORTHODONTIC INSURANCE
Insured's Name:
Birthdate

MonthDayYear
Insurance Company Name
Insurance Company Phone #

Area CodePhone Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Group #:
ID #:
EMERGENCY CONTACT INFORMATION
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relation to Patient:
MEDICAL HISTORY
PHYSICIAN:
Date of Last Visit
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Allergies

	Yes	No	Please List
Are you allergic to any latex, metals, nickel or plastics? If yes please list
Are you allergic to any medication/things? If yes please list

Have you ever had any of the medical conditions listed below:

	Yes	No
Abnormal Bleeding
ADD/ADHD
Anemia
Arthritis
Artificial Bones/Joints/Valves
Asthma
Bone Disorders
Cancer/Tumor
Congenital Heart Defect
Diabetes
Dizziness
Epilepsy/Seizures
Gastrointestinal Disorders
Hearing Impairment
Heart Problems/Murmur
Hemophilia
Hepatitis/Liver Problem
Herpes/Fever Blisters
High/Low Blood Pressure
HIV +/AIDS
Kidney Problems
Nervous Disorders
Pneumonia
Prolonged Bleeding
Psychiatric Problems
Radiation/Chemotherapy
Rheumatic Fever
Severe/Frequent Headache
Sinus Problems
Tuberculosis (TB)

Are you taking any medication? Please List:
Do you have a history of a major illness? Please List:
Have you had any operations or been involved in a serious accident? Please list:
Are there any handicaps/disabilities that we should be aware of?
Are there any medical conditions we have not discussed that you feel we should be aware of?
For Women: Are you pregnant? Week #:
DENTAL HISTORY
General Dentist
Date of Last Visit

MonthDayYear
Date
What concerns you most about your teeth?

Have you ever had any of the habits listed below:

	Yes	No
Clenching Teeth
Grinding Teeth
Lip Sucking
Lip Biting
Mouth Breathing
Nail Biting
Speech Problems
Tongue Thrust

Please tell us about your dental health

	Yes	No	If Yes Please explain
Have you ever been evaluated for orthodontic treatment?
Are you sensitive or self-conscious about your teeth?
Has anyone in the family received orthodontic treatment? If yes, how did they feel about the result?
Have you ever experienced any unfavorable reaction to dentistry?
Are you presently in any dental pain?
Is any part of your mouth sensitive to temperature or pressure? Where?
Have there been any injuries to your face, mouth or teeth?
Have you been informed of any missing or extra teeth?
Have you ever lost or chipped any permanent teeth?
Do your gums bleed when brushing?
Have your wisdom teeth been removed?
Do teeth or jaws ever feel uncomfortable first thing in the morning?
Do you ever experience jaw clicking or popping?
Do you experience "tension" headaches?

I understand that I am responsible for payment of services rendered and also for paying any co-payments and deductibles that my insurance does not cover. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.
Patient Signature

Clear
Date
This office reserves the right to verify the credit status of patients and/or their parents prior to extending credit for orthodontic fees and may, at the discretion of the office, use the services of one or more credit reporting services.
Patient Signature

Clear
Date
I grant Dr. Jay M. Decoteau, D.M.D., P.C. (AKA: Decoteau Orthodontics) the right to use my images for the purpose of advertising and marketing, including but not limited to, their website, local newspaper and magazine ads, Facebook and other social media, and any in office media. I release Dr. Jay M. Decoteau, D.M.D., P.C., from any claims that may arise regarding the use of my image.
Patient's Name:

First NameLast Name
Date
Signature (If over 18)

Clear
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES

* You May Refuse to Sign
I have received a copy of the Notice of Privacy Practices.

YesNo
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

ADULT PATIENT INFORMATION

SPOUSE INFORMATION

DENTAL INSURANCE INFORMATION

MEDICAL HISTORY

DENTAL HISTORY

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES