UMITEDTO

ADULT NEW PATIENT INFORMATION
We consider it a privilege to welcome you to our office. In an effort to provide the best treatment possible, we ask that you complete this form as completely as possible. We value your time and appreciate your cooperation.
LAST NAME
FIRST NAME
MIDDLE INITIAL
GENDER
ADDRESS
BIRTHDATE

MonthDayYear
Date
E-MAIL
example@example.com
MARITAL STATUS
HOME PHONE #
CELL PHONE #
CELL PHONE CARRIER (Verizon, AT&T, Sprint, etc)
EMPLOYER
OCCUPATION
GENERAL DENTIST
LAST DENTAL VISIT
Whom may we thank for referring you to our office?
SPOUSE/ADDITIONAL CONTACT
LAST NAME
FIRST NAME
MIDDLE INITIAL
GENDER
ADDRESS
BIRTH DATE

MonthDayYear
Date
E-MAIL
example@example.com
MARITAL STATUS
HOME PHONE #
CELL PHONE #
CELL PHONE CARRIER (Verizon, AT&T, Sprint, etc)
EMPLOYER
OCCUPATION
PATIENT MEDICAL HISTORY
Are you under the care of a physician?

YESNO
If YES, please explain
Physician
Phone
Last Visit
Address
Are you pregnant?

YESNO
If YES, how many weeks along?
What are your main concerns regarding orthodontic treatment?
Have you ever been evaluated for orthodontic treatment?

YesNo
Has the patient had tonsils or adenoids removed?

YesNo
Has the patient ever experienced jaw joint pain/discomfort (TMJ/TMD)?

YesNo
Does the patient have any missing or extra permanent teeth?

YesNo
Do you have any speech problems?

YesNo
Do your gums bleed?

YesNo
Do you smoke?

YesNo
Do you like your smile?

YesNo
Has the patient ever had an injury to: (select all that apply)

TeethMouthChin
Please check if you've had, or currently have any of the following habits.

Clenching / Grinding TeethLip Sucking / BitingMouth BreathingTongue ThrustingProlonged Bottle / PacifierNail BitingFinger / Thumb Sucking
Please check if you are allergic to any of the following.

AspirinErythromycinCodeinePenicillinTetracyclineLatexMetalsPlastics
Any other allergies / sensitivities?
Please list any drugs you are currently taking and/or serious medical conditions.
I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidence, and it is my responsibility to inform this office of any changes in my medical status. I hereby authorize the release of any information related to insurance claims. I consent to the examination by the doctor.
Printed Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

ADULT NEW PATIENT INFORMATION

SPOUSE/ADDITIONAL CONTACT

PATIENT MEDICAL HISTORY