New Patient Information Form
Welcome to Schatz Orthodontics. Please let us know if you have any questions about this form. Be sure to enter N/A for any fields that do not apply.
Patient Name
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
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Gender
*
Male
Female
Age
*
Birthdate
*
-
Month
-
Day
Year
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Home Phone
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
For whom are you seeing orthodontic treatment?
*
Child(ren)
An Adult (myself or someone else)
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Child's School
*
Grade
*
Child's Responsible Party
*
First Name
Last Name
Father's Name
First Name
Last Name
Father's Employer
Position
Business Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Mother's Name
First Name
Last Name
Mother's Employer
Position
Business Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
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Employer
*
Position
*
Business Phone
Please enter a valid phone number.
Cell Phone
*
Please enter a valid phone number.
Spouse's Name
First Name - Please type N/A if not applicable.
Last Name
Spouse's Employer
Please type N/A if not applicable.
Spouse's Position
Please type N/A if not applicable.
Spouse's Business Phone
Please enter a valid phone number. Please type N/A if not applicable.
Spouse's Cell Phone
Please enter a valid phone number. Please type N/A if not applicable.
Children - Name(s) and Age(s)
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What would you like to see changed about your/your child's teeth?
*
Is there any significant medical history that we should be aware of?
*
Is there any significant dental history that we should be aware of?
*
Patient's Dentist and City
*
Allergies
*
Allergic to latex?
*
Yes
No
Whom may we thank for referring you to our office?
Friends or relatives treated here:
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