Constant and Contro Orthodontics
Dr. David Constant and Dr. Curtis Contro
New Patient Registration
Thank you for scheduling a new patient exam. We are excited to meet you! In order to maximize your time with the doctor, please fill this form out ahead of time.
Patient's Name
*
First Name
Last Name
Nickname
Today's Date
*
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Month
-
Day
Year
Date
Patient/Guardian's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient/Guardian's Phone Number
*
-
Area Code
Phone Number
Patient/Guardian's Email
*
example@example.com
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Patient's Age
*
Patient's Grade
Patient's Marital Status
Married
Single
Patient's Gender Identity
*
Male
Female
Transgender
Non-binary
Not otherwise specified
Patient's Occupation
Employer
Work Phone Number
-
Area Code
Phone Number
Who may we thank for referring you?
*
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Patient's Family Information
You may skip this section if you are NOT registering a minor
Father's Name
First Name
Last Name
Father's Address (if different than patient's)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Phone Number
-
Area Code
Phone Number
Father's Email
example@example.com
Father's Occupation/Employer
Mother's Name
First Name
Last Name
Mother's Address (if different than patient's)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Phone Number
-
Area Code
Phone Number
Mother's Email
example@example.com
Mother's Occupation/Employer
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Dental Insurance Information
Primary Insured
First Name
Last Name
Social Security Number
Date of Birth
-
Month
-
Day
Year
Date
Employer
Insurance Company
Insurance Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance ID Number
Insurance Group Number
Secondary Insured
First Name
Last Name
Social Security Number
Date of Birth
-
Month
-
Day
Year
Date
Employer
Insurance Company
Insurance Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance ID Number
Insurance Group Number
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Medical History
Name of Medical Doctor
First Name
Last Name
Date of Last Visit
-
Month
-
Day
Year
Date
Medical Doctor's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical Doctor's Phone Number
-
Area Code
Phone Number
Please answer the following medical questionnaire.
*
Yes
No
Have you had a complete physical in the last year?
Are you presently under a physician's care?
Have you had major surgery?
Have you ever been hospitalized?
Are you taking any pills, medications, or drugs?
Are you allergic to novocaine or penicillin?
Have you had any unusual reactions to any medications?
Have you had your tonsils or adenoids removed?
Do you ever have fainting or dizzy spells?
Do you have high blood pressure?
Do you have low blood pressure?
Please list the medications you are taking here. If none, type "none".
*
Please list your drug allergies here. If none type "none".
*
Do you have or have you had any of the following?
*
Yes
No
Heart problems
Kidney problems
Lung problems
Liver problems
Allergies
Allergic to latex
Diabetes
Epilepsy
Arthritis
Anemia
Tuberculosis
Hepatitis
AIDS/HIV
Rheumatic fever
Mental health problems
Malignancies/cancer
Endocrine problems
Bone disorders
Prolonged bleeding
Asthma
Please use this space to give more details about your answer above. For example, you may list your allergies here.
Patient/Guardian's Signature
*
Clear
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Dental History
Dentist's Name
First Name
Last Name
Date of Last Visit
-
Month
-
Day
Year
Date
Dentist's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dentist's Phone Number
-
Area Code
Phone Number
Please describe your/the patient's main concern with the patient's teeth?
*
A picture is worth a thousand words, so feel free to upload a picture of your main concern with the patient's teeth.
Please answer the following questions about the patient's dental health.
*
Yes
No
Has the patient had previous orthodontic consultations?
Has the patient had previous orthodontic treatment?
Has any family members had orthodontic treatment?
Has the patient been informed of any extra or missing teeth?
Has the patient had any permanent teeth removed by extraction?
Does the patient suck his/her thumb or finger?
Does the patient breathe predominantly through his/her mouth?
Does the patient have speech problems?
Does the patient grind or clench his/her teeth?
Does the patient have pain or clicking of the jaw joint?
Has the patient had any teeth injured or chipped due to an accident?
Has the patient ever had chronic pain in the face or head?
Has the patient ever had a jaw or head injury?
Does the patient get chronic sores inside his/her mouth?
Does the patient's gums bleed upon brushing or flossing?
Has the patient ever been treated for gum disease?
Has the patient ever had an unpleasant dental experience?
Is the patient concerned about the appearance of his/her teeth?
Does the patient want his/her teeth straightened?
Please feel free to use this space to elaborate on "yes" answers above or detail anything not asked above.
Responsible Party
*
First Name
Last Name
Patient/Guardian Signature
*
Clear
I acknowledge that I have received from the office of Dr. Constant and Contro a copy of the DENTAL NOTICE OF PRIVACY PRACTICES:
*
Clear
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