Welcome to the Orthodontist

Adult New Patient Form
We would like to welcome you and your child to our office. Our goal is to make everyone's 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.
Information Must Be Filled Out Completely
Name*

PrefixFirstLast
I prefer to be called:
Marital Status:
Birthdate

MonthDayYear
Date
Social Security Number
Email*
General Dentist:*
Date of Last Appointment*
Drivers License #*
Whom may we Thank for referring you?
Other Family Members Seen By Us
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone #

Area CodePhone Number
Cell Phone #

Area CodePhone Number
Work Phone #

Area CodePhone Number
Employer Information
Employer Name*
How Long There?*
Occupation*
Best Place to Reach You*
Spouse Information
Name

First NameLast Name
Birthdate
Cell #

Area CodePhone Number
Home Phone #

Area CodePhone Number
Work Phone #

Area CodePhone Number
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Social Security #
Driver's License #
Person Responsible for Account
Name

First NameLast Name
Cell #

Area CodePhone Number
Home Phone #

Area CodePhone Number
Work Phone #

Area CodePhone Number
Employer*
Social Security #*
Primary Orthodontic Insurance
Orthodontic Coverage*

YesNo
Policy Holder's Name

First NameLast Name
Policy Holder's Birthdate

MonthDayYear
Date
Social Security #
Employer Name
Insurance Company
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone #

Area CodePhone Number
Group ID #
Member ID
Relationship to Patient
Secondary Orthodontic Insurance
Orthodontic Coverage*

YesNo
Policy Holder's Name

First NameLast Name
Policy Holder's Birthdate

MonthDayYear
Date
Social Security #
Employer Name
Insurance Company
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone #

Area CodePhone Number
Group ID #
Member ID
Relationship to Patient
Medical History
Do you have a personal physician?*

YesNo
Physician Name
Date of Last Visit

MonthDayYear
Date
Please describe your physical health

ExcellentGoodFairPoor
Please list all medications that you are currently taking and for what conditions:
Please list any medications that you are currently allergic to:
For Women
Are you currently on a birth control pill?*

YesNo
Are you pregnant?*

YesNo
Are you nursing?*

YesNo

Have you ever had any of the following medical problems?

	Yes	No
Abnormal Bleeding
Allergies to any drugs
Allergy to latex/metals
Allergy to plastic
Any Operations
Asthma
Cancer
Congenital Heart Defect
Diabetes
Epilepsy/Convulsions
Handicaps/Disabilites
Hearing Impairment
Heart Murmur
Hemophilia
Hepatitis
Kidney / Liver Problems
Rheumatic Fever
Tuberculosis (TB)
Any Hospital Stays
HIV +/AIDS

What are the main concerns you and/or your dentist would like orthodontics to address?
Explain
Has you ever had or been evaluated for orthodontic treatment before?
Have there been any injuries to the face, teeth, jaw, mouth, or chin? Please explain:
Have adenoids or tonsils been removed?*

YesNo
Have you been informed of any missing or extra permanent teeth?

YesNo
If yes, which ones?
Have you ever had pain/tenderness in the jaw joint? (TMJ, TMD)?*

YesNo
Do you brush your teeth daily?*

YesNo
Do you floss your teeth daily?

YesNo

Do you have any of the following habits?

	Yes	No
Clenching/Grinding Teeth
Speech Problems
Mouth Breather
Nail Biting

Please list an emergency contact not living with you
Name

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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*

YesNo
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

**You May Refuse to Sign This Acknowledgement**
I ________________________ , have received a copy of this office's Notice of Privacy Practices.
MyselfChild(ren)
Name of Childr(ren)
Name

First NameLast Name
Date

MonthDayYear
Date
Signature

Clear
Other (please specify)
Should be Empty:

Adult New Patient Form

Information Must Be Filled Out Completely

Employer Information

Spouse Information

Person Responsible for Account

Primary Orthodontic Insurance

Secondary Orthodontic Insurance

Medical History

What are the main concerns you and/or your dentist would like orthodontics to address?

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES