New Patient Form
Patient Name
*
First Name
Last Name
Patient Nickname
SS#
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Birth Date
*
-
Month
-
Day
Year
Date
Age
*
Gender
*
Cell Phone
*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
School
Grade
Whom may we thank for referring you to our office?
Other family members seen by us?
General Dentist
General Dentist Location
Siblings (Please list names & ages)
Who is with the child today?
Name
Relationship
Do you have legal custody of this child?
Yes
No
Responsible Party Information
Applies to minors only
Father's Name (or Self)
Email
example@example.com
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SS#
Birth Date
-
Month
-
Day
Year
Date
DL#
Relationship to Patient
Employer
Work Phone
Please enter a valid phone number.
Mother's Name (or Spouse)
Email
example@example.com
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SS#
Birth Date
-
Month
-
Day
Year
Date
DL#
Relationship to Patient
Employer
Work Phone
Please enter a valid phone number.
Marital Status:
Single
Married
Divorced
Widowed
Person financially responsible for this account:
Father/self
Mother
Orthodontic Insurance Information
Primary Insured Name
Birth Date
-
Month
-
Day
Year
Date
SS#
Insurance Company
Group No.
Employer
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Co. Phone
Please enter a valid phone number.
Do you have dual coverage?
Yes
No
Emergency Information
Name of nearest relative not living with you
*
Phone
*
Please enter a valid phone number.
Complete Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dental History
Why is the patient being seen by the Orthodontist today?
Has the patient ever had any pain or tenderness in the jaw joint (TMJ/TMD)
*
Yes
No
Has the patient ever had a serious/difficult problem associated with dental work?
*
Yes
No
Is the patient's water fluoridated?
*
Yes
No
Is the patient taking fluoridated supplements?
*
Yes
No
Does the patient brush teeth daily?
*
Yes
No
Types of bristles?
*
Hard
Medium
Soft
Floss their teeth daily?
*
Yes
No
Does the patient like their smile?
*
Yes
No
Does the patient's gums ever bleed?
*
Yes
No
Medical History
Does the patient have a personal physician?
*
Yes
No
Is the patient currently under the care of a doctor? (If yes, please explain)
Please describe the patient's health:
Good
Fair
Poor
Please list all drugs the patient is currently taking:
Does the patient have any of the following habits?
*
Yes
No
Thumb Sucking/Finger Sucking
Lip Sucking/Biting
Nail Biting
Nursing Bottle Habits
Has the patient ever had any of the following diseases or medical problems?
*
Yes
No
Prosthesis
Heart attack
Cancer
Diabetes
Rheum. Fev.
HIV/AIDS
Hemophilia
Asthma
Hepatitis
Tuberculosis
Shingles
Fever Blister
Venereal Disease
Ulcers/Colitis
Heart Murm.
Emphysema
Sinus Problems
Hearing Impairment
History of Scarlet Fever
Congenital Heart Def.
Convulsions/Epilepsy
Abnormal Bleeding
Artificial Valves
Heart Surgery/Pacemaker
Any Stays in Hospital
Kidney/Liver Problems
Mitral Valve Prolapse
Artificial Bones/Joints
Sev./Freq. Headaches
Hi/Lo Blood Pressure
Drug/Alcohol Abuse
Blood Transfusion
Anemia/Radiation Tmt.
Glaucoma
Difficulty Breathing
Handicaps/Disabilities
Is the patient allergic to any of the following?
Aspirin
Latex
Erythromycin
Tetracycline
Codeine
Penicillin
Dental Anesthetics
Other
For women only:
Are you taking birth control pills?
Yes
No
Are you nursing?
Yes
No
Are you pregnant?
Yes
No
If yes, week #
Signature
To the best of my knowledge, all of the preceding answers are true and accurate. If I (or the patient) ever have any change in health status or medications being taken or if I (or the patient) have any abnormal medical test results, I will inform the dentist at the next appointment without fail. I authorize the dental staff to perform the necessary treatment for the purpose of comprehensive filing of insurance claims. I authorize payment of primary insurance benefits directly to the dentist otherwise payable to me. I acknowledge full responsibility for the payment of services at the time of service unless other arrangements are made with this office.
Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: