New Patient Information

New Patient Information - Adult
Name*

First NameLast Name
Nickname or Prefers to be called
Gender*

MaleFemale
Identifies As

MaleFemaleTransgenderNon-binary/non-conformingPrefer not to respond
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Contact Number*
Please enter a valid phone number.
Marital Status

SingleMarriedSeparatedDivorcedWidowed
Employer
Occupation
Spouse's Name

First NameLast Name
Spouse's Phone Number
Please enter a valid phone number.
Email*
example@example.com
Which method(s) would you prefer to receive notifications of future appointments? Check all that apply.*

EmailText messageNoneI allow treatment information to be left on voicemailI allow financial information to be left on voicemail
Who may we thank for referring you to our office?*
What concerns you most about your teeth?*

CrowdingSpacingOverbiteUnderbiteCrossbiteOther (please specify in box below)
I am most interested in:

BracesInvisalign
Other concerns
General Dentist*
Date of last visit*

MonthDayYear
Date
Dental Insurance Information

If you have dental insurance, please provide the following information so we can verify your benefits before your scheduled appointment.
Policy Holder's Name

First NameLast Name
Policy Holder's Date of Birth

MonthDayYear
Date
Policy Holder's Social Security Number
Relationship to Policy Holder
Policy Holder's Employer
Insurance Company Name
Insurance Company Phone Number
Please enter a valid phone number.
Member ID
Group Number
Please upload a photo of the front of your insurance card here

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Please upload a photo of the back of your insurance card here

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Medical History
Have you ever had any of the following medical concerns? (Check all that apply)*

Abnormal bleedingADHDAnemiaAnxiety/Behavioral IssuesArtificial Bones/Joints?ValvesAsthma/ArthritisAutismBlood TransfusionBlood DiseaseBone DisordersBronchitisCancer/ChemotherapyCongenital heart defectsDevelopmental DisorderDiabetesDifficulty BreathingDrug AbuseEmotional ProblemsEmphysemaEndocrine DisorderEpilepsy/Seizures/FaintingFever Blisters/HerpesFrequent HeadachesGlaucomaGrowth DisordersHeart Attack/StrokeHeart MurmurHeart Surgery/PacemakerHemophiliaHepatitisHigh/Low Blood PressureHIV+/AIDSHives/RashHospitalized for Any ReasonKidney ProblemsLiver DiseaseMitral Valve ProlapseMouth BreathingNervous/AnxiousOsteoprosis/Bone DensityPsychiatric ProblemsRadiation TreatmentRheumatic/Scarlet FeverSever/Frequent HeadachesShinglesSickle Cell Disease/TraitsSinus ProblemsSleep ApenaSnoringTonsillitisTuberculosisUlcers/ColitisNo Medical ConcernsOther (Please indicate in the box below)
Other Medical Concerns
Are you allergic to any of the following? (Check all that apply)*

AspirinAny Metals/PlasticsCodeineDental AnestheticsErythromycinLatexPenicillinSulfa DrugsTetracyclineNo AllergiesOther (Please indicate in the box below)
Other Allergies
Please list any medications being taken
Have you ever had any of the following dental concerns? (Check all that apply)*

Have you ever sucked thumb or fingers?Do you predominately breathe through the mouth?Do you have any speech problems?Do you clench or grind teeth (at night)?Do you have pain or clicking upon opening/closing the mouth?Have you had any severe head or face injuries?Have any teeth been chipped due to accidents?Have you been informed of missing permanent teeth?Have you been informed of any extra teeth?Were any teeth (baby or permanent) removed by extraction?Was it suggested that the space be maintained?Was an appliance placed to maintain the space?Have you ever had any previous orthodontic consultation or treatment?Does anyone in the family have similar dental concerns?Would you mind wearing "braces"?Any noticeable difficulty in chewing or swallowing food?Has anyone in the family been told they have short roots?NoneOther (Please indicate in box below)
Other Dental Concerns
For Women
Are you pregnant?

YesNo
Due date

MonthDayYear
Date
I certify that the above information is complete and accurate. I also understand that I am responsible for updating any changes or additions to this information in the future.
Patient Signature

Clear
Today's Date

MonthDayYear
Date

New Patient Information - Adult