Winnie Orthodontics New Patient Form for ADULT Patients

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NEW PATIENT FORMS - ADULT (18 YEARS AND OLDER)
Name*

First NameLast Name
Nickname
Birth date*

MonthDayYear
Date
Gender*

MaleFemale
Email*
Home Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
GENERAL INFORMATION
Who may we thank for recommending our office to you?*
General Dentist*
Last Visit Date

MonthDayYear
Date
Dentist Phone Number
EMERGENCY CONTACT INFORMATION
Name of Emergency Contact*

First NameLast Name
Phone Number of Emergency Contact*
Please enter a valid phone number.
Relationship of Emergency Contact to Patient*
INSURANCE INFORMATION
Insurance Company Name *
Insurance Phone #
Group #
Subscriber ID OR Social Security Number (enter "0" if no insurance)*
Please Upload Your Driver License or Picture ID *

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Please Upload the FRONT of your insurance card

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Please Upload the BACK of your insurance card

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MEDICAL HISTORY
Name of Family Physician
Phone Number of Family Physician
Please enter a valid phone number.
Your current physical health is:*

GoodFairPoor
Are you currently under the care of a physician?*

YesNo
If Yes, please explain:
Do you smoke or use tobacco of any kind?*

YesNo
Have you had any metal rods, pins or implants?*

YesNo
Are you taking any prescription/over-the-counter medications?*

YesNo
If Yes, please list each one:
If female, Are You Pregnant?

YesNo
If Yes, How Many Weeks?
Are you nursing?

YesNo

Have you ever had any of the following diseases or medical problems:*

	Yes	No
Abnormal bleeding/Hemophilia
AIDS
Anemia
Arthritis
Artificial bones/Joints/Valves
Asthma
Blood Transfusion
Cancer/Chemotherapy
Congenital Heart Defect
Diabetes
Difficulty Breathing
Emphysema
Epilepsy
Fainting Spells
Frequent Headaches
Glaucoma
Hay Fever
Heart Attack/Surgery
Heart Murmur
Hepatitis
Herpes/Fever Blisters
High Blood Pressure
HIV
Hospitalized for any reason
Kidney Problems
Liver Disease
Low Blood Pressure
Lupus
Mitral Valve Prolapse
Pacemaker
Psychiatric Problems
Radiation Treatment
Rheumatic/Scarlet Fever
Seizures
Shingles
Sickle Cell Disease/Traits
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis (TB)
Ulcers
Venereal Disease

List any other medical condition(s) that you have ever had:

Are you ALLERGIC to any of the following?*

	Yes	No
Aspirin
Erythromycin
Penicillin
Codeine
Jewelry/Metals
Tetracycline
Dental Anesthetics
Latex
Other (please specify below)

Other Allergies Not Listed Above
DENTAL HISTORY
What are the main orthodontic concerns you would like to accomplish?*
Have you ever been evaluated for orthodontic treatment*

YesNo
Have you ever experienced pain or discomfort in their jaw joint (TMJ/TMD)? If Yes, please describe history and duration of problem
Please list any injury you have ever had to the oral and facial areas:
Do you require antibiotics before dental procedures?*

YesNo
How many times do you brush daily?*
How many times do you floss daily?*
What orthodontic treatment are you interested in?*

Traditional metal bracesCeramic clear bracesClear AlignersLingual BracesOther
What is most important to your care? Please select all that apply.*

EstheticsTechnologyPriceComfortSpeedConvenience
Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

I hereby confirm that the information I have given is correct to the best of my knowledge, that it will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental/orthodontic services my child may need.

I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance company does not cover. I authorize Winnie Orthodontics to release all information necessary to secure the payment of benefits. I assign directly to the doctor all insurance benefits otherwise payable to me. I further authorize the use of this signature on all my insurance submissions, whether manual or electronic.
Patient's Signature*

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Date*

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Date
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NEW PATIENT FORMS - ADULT (18 YEARS AND OLDER)

GENERAL INFORMATION

EMERGENCY CONTACT INFORMATION

INSURANCE INFORMATION

MEDICAL HISTORY

DENTAL HISTORY