Adult New Patient Form
Patient Information
Patient Name
*
First Name
Last Name
Gender
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Primary Phone
*
Please enter a valid phone number.
Secondary Phone
Please enter a valid phone number.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
Occupation/Job Title
Work Phone
Please enter a valid phone number.
Number of Years at Current Job
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Relationship to Patient
*
Who may we thank for referring you to Serrano Orthodontics?
Have we treated any additional family members?
Yes
No
If yes, please list their names
Spouse/Partner Name (If Applicable)
First Name
Last Name
Dental Insurance Information
(If you have it)
Insurance Company Name
Insurance Company Phone
Please enter a valid phone number.
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy Owner's Name
First Name
Last Name
Social Security #
Date of Birth
-
Month
-
Day
Year
Date
Relationship to Patient
Policy Owner's Employer
Group, Plan or Policy #
Member ID #
Secondary Dental Insurance
(If you have it)
Insurance Company Name
Insurance Company Phone
Please enter a valid phone number.
Policy Owner's Name
First Name
Last Name
Social Security #
Date of Birth
-
Month
-
Day
Year
Date
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to Patient
Policy Owner's Employer
Group, Plan or Policy #
Member ID #
Medical Insurance
Insurance Company Name
Insurance Company Phone
Please enter a valid phone number.
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy Owner's Name
First Name
Last Name
Social Security #
Date of Birth
-
Month
-
Day
Year
Date
Relationship to Patient
Policy Owner's Employer
Group, Plan or Policy #
Member ID #
Motivation for Treatment: The Teeth
If your teeth could be changed, how would you like them to change?
Make the upper front teeth
No Change
Longer
Shorter
Move upper teeth
No Change
Forward
Backward
Move lower teeth
No Change
Forward
Backward
Make the line of the upper teeth more level
No Change
Yes
No
Other
Please describe any other changes you would like to make with your teeth.
The Face
If your facial appearance could be changed, what would you change?
Get rid of sag under lower jaw
No Change
Yes
No
Move chin
No Change
Forward
Backward
Move chin to center it
No Change
Left
Right
Move lower lip
No Change
Forward
Backward
Move upper lip
No Change
Forward
Backward
Move the area around my nose
No Change
Forward
Backward
Make the profile of my nose
No Change
Longer
Shorter
Move the area under my eyes
No Change
Forward
Backward
Make my cheekbones
No Change
Larger
Smaller
When my teeth are touching, make my lips
No Change
Closer Together
Farther Apart
When my teeth are touching, make my lips not touch and roll out
No Change
Yes
No
Make my face more
No Change
Narrow
Wide
Reduce my lower jaw behind my mouth
No Change
Width
Fullness
Other
Please describe any other changes you would like to make with your face.
Symptoms
If you want to reduce pain or discomfort where is it located? Please be specific about the location; select right side, left side or both if they apply.
In front of my ears
None
Left
Right
Both
Below my ears
None
Left
Right
Both
Above my ears
None
Left
Right
Both
In my ears
None
Left
Right
Both
Neck
None
Left
Right
Both
Shoulders
None
Left
Right
Both
Temples
None
Left
Right
Both
Teeth
None
Left
Right
Both
Sinuses
None
Left
Right
Both
Eyes
None
Left
Right
Both
Other
Please describe any other symptoms you would like to treat.
Dental Information
Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment your you receive from our office. This information is kept strictly confidential.
Dentist Name
Dentist Phone Number
When was your last dental cleaning?
*
Within last 3 months
Within last 6 months
Within last 12 months
Over 12 months ago
Exact date
Unknown
Do you have any pending or planned dental work to be completed?
*
Yes
No
Did your dentist refer you to our office?
Yes
No
What is your main orthodontic concern?
*
What are your thoughts or feelings about the possibility of Orthodontic treatment?
Have you ever had a previous orthodontic exam?
*
Yes
No
Have you ever had previous orthodontic treatment?
*
Yes
No
Now, or in the past, have you had issues with any of the following: (please check all that apply, or choose NONE)
*
Untreated cavities
Teeth extracted (baby or permanent)
Thumb or finger sucking habit
Impacted teeth
Sensitive or sore teeth
Supernumary (extra) teeth
Tooth grinding or clenching
Congenitally missing teeth
Mouth breathing
Bleeding gums
Snoring and/or sleep apnea
Gum disease
Tongue thrusting or sucking
Swelling or growths in the mouthLip biting
Problems eating, chewing, or swallowing
NONE
Do you currently have any areas of irritation (pain, sores) in or around your mouth?
*
Yes
No
Have you ever had any injury to yout face, mouth, or teeth?
*
Yes
No
Do you now, or have you ever, experienced pain or discomfort in your jaw (i.e. TMJ/TMD issues)?
*
Yes
No
Medical Information
Are you presently in good health?
*
Yes
No
Are you currently under the care of a Physician?
*
Yes
No
Do you have a personal or family Physician?
*
Yes
No
Are you currently taking any prescription or non-prescription medications or supplements?
*
Yes
No
Do you have any known allergies to any drugs or medications?
*
Yes
No
Do you have any non-medication related allergies?
*
Yes
No
Have you had any hospitalizations or major illnesses in the last 5 years?
*
Yes
No
Have your tonsils or adenoids been removed?
*
Yes
No
Do you require antibiotic medicine prior to dental treatments?
*
Yes
No
Are there any other physical, mental, or medical issues we should be aware of?
*
Yes
No
Medical History
Now, or in the past, have you had: (please check all that apply, or choose NONE)
Asthma
Bone fractures
Blood pressure problems
Mental health disturbances
Birth defects/hereditary problems
Cancer/Chemotherapy
Arthritis/joint problems
Eating disorder
Seizures/neurological problems
Osteoperosis
Endocrine or thryoid problems
Diabetes
Bleeding problems
Mitral valve prolapse
Heart defects/disease
Kidney problems
Speech problems
Immune system problems
Frequent headaches or migraines
AIDS/HIV+
ADD/ADHD
Anemia
Bone disease
Tuberculosis
Thyroid or Endocrine problems
Artificial bones/joints
Drug or Alcohol Abuse
Heart attack
Heart murmur
Heart surgery/pacemaker
Congenital heart defect
Artificial heart valves
Blood transfusion
Ulcers
Stroke
Difficulty breathing
Liver disease
Psychiatric treatment
Glaucoma
Fainting spells
Venereal disease
NONE
Other
Privacy Notice
Insurance Release and Agreement
I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company. I understand that I am responsible for payment of services rendered as well as any co-payments or deductibles.
Signature
*
Clear
Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature/Verification of Information
I hereby state that I have read, understand and have truthfully, to the best of my ability answered all questions containted on this form. I will not hold my Orthodontist or any member of their staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my Orthodontist of any changes in medical or dental health. I authorize the Orthodontist or their staff to perform any necessary dental services that I may need. I authorize this practice to share treatment with collaborating dentists, surgeons, or other professionals when appropriate.
Signature
*
Clear
Name
First Name
Last Name
Location
Chandler Office
Phoenix Office
Click submit to securely send this form to our practice.Please note that further signatures may be required in the office.
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