New Patient Form
Patientsʼ Full Name
*
Nickname
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Home Phone
Please enter a valid phone number.
Cell Phone
*
Please enter a valid phone number.
Contact email
*
example@example.com
Patientʼs Dentist
*
Date of last visit
-
Month
-
Day
Year
Date
If patient is an adult, please fill out this section:
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employed by
Bus. Phone
Please enter a valid phone number.
Spouseʼs Full Name
Employed by
Bus. Phone
Please enter a valid phone number.
If patient is a student, please fill out this section:
School
Grade
Fatherʼs Full Name
Father's Home Address (If different from patient)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father Employed by
Bus. Phone
Please enter a valid phone number.
Motherʼs Full Name
Mother's Home Address (If different from patient)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother Employed by
Bus. Phone
Please enter a valid phone number.
All patientsʼ please fill out the remainder of the form:
Person Responsible for Account
*
SSN
Address (If different from home address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patientʼs Physician
*
Is there any orthodontic insurance we can check for you?
*
Yes
No
Social Security Number or Member ID
*
Insurance Company
Policy Holder
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
DOB
-
Month
-
Day
Year
Date
SSN
Employer
Relatives treated at this office
Have you been under the care of a physician during the past two years?
*
Yes
No
If so, state condition and duration:
Please check any of the following for which you have been treated:
*
Diabetes
Anemia
Epilepsy
Fainting or Dizziness
Pneumonia
Asthma
Nervous Disorder
Hepatitis or Jaundice
Heart Trouble
Rheumatic Fever
Kidney Trouble
HIV
Bone Disorders
Tuberculosis
Endocrine Problem
Prolonged Bleeding
None
List any medications now being taken
List any allergies or drug sensitivity
Have your tonsils or adenoids been removed?
*
Yes
No
If yes, at what age?
Have you ever sucked your thumb or finger?
*
Yes
No
If yes, until what age?
Do you have any speech problems?
*
Yes
No
Are you a mouth breather?
*
Yes
No
Do you play a musical wind instrument?
*
Yes
No
Has another orthodontist been consulted previously?
*
Yes
No
Signature
Whom may we thank for referring you to our office?
Signature of Patient, Parent, or Guardian
*
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: