Adult New Patient Form

Adult New Patient Form
Patient Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Age*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone No.*
Please enter a valid phone number.
Primary Phone Type*

HomeCell
Secondary Phone No.*
Please enter a valid phone number.
Secondary Phone Type*

HomeCell
E-mail Address*
example@example.com
How did you hear about our practice?*
Name of Person Referring (if applicable)
Employer's Name
Occupation
Spouse/Emergency Contact Information
Marital Status*

SingleMarriedDivorcedWidowedSignificant Other
Spouse/Partner's Name*
Emergency Contact Name*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person(s) OK to release appointment or medically related information to concerning you.*
Relation*
Dental Insurance Information
Primary Insurance Company
Phone Number
Please enter a valid phone number.
Group No.
Policy No.
Member ID No.
Policy Holder's Name
Policy Holder's Social Security Number
Policy Holder's Birth Date

MonthDayYear
Date
Employer
Work Phone Number
Please enter a valid phone number.
Co-pay (if known)
Deductible (if known)
Secondary Insurance Company
Phone Number
Please enter a valid phone number.
Group No.
Policy No.
Member ID No.
Policy Holder's Name
Policy Holder's Social Security Number
Policy Holder's Birth Date

MonthDayYear
Date
Employer
Work Phone Number
Please enter a valid phone number.
Co-pay (if known)
Deductible (if known)
Dental History
General Dentist
Last Visit
How did you hear about our Practice?

AdInternetFamily or FriendPhysicianOther
Name of person referring (if applicable)
What are the main concerns you would like orthodontics to accomplish?*
Have you visited an orthodontist before?*

YesNo
Have your tonsils or adenoids been removed?*

YesNo
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?*

YesNo
Do you have any missing or extra permanent teeth?*

YesNo
Have you ever had an injury to (select all that apply)*

TeethMouthChinNo
Do you have speech problems?*

YesNo
Do your gums bleed?*

YesNo
Do you smoke?*

YesNo
Do you like your smile?*

YesNo
Do you currently or have you ever had any of the following habits?*

Clenching/Grinding TeethLip Sucking/BitingMouth BreathingNail bitingThumb/ Finger SuckingChewing/Eating ProblemsNone
Medical History
Are you currently being treated by a physician?*

YesNo
Do you have any allergies/sensitivities to medications or latex?*

YesNo
Are you currently taking any prescription or over-the-counter medications?*

YesNo
(WOMEN) Is the patient pregnant?*

YesNoN/A
Have you had any serious illnesses or operations? If yes, describe:
Check if you have or have ever had any of the following*

AnemiaArthritis, RheumatismArtificial Heart ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseCancerChemical DependencyChemotherapyCirculatory ProblemsCortisone TreatmentsCough, PersistentCoughing BloodDiabetesEpilepsyFaintingGlaucomaHeadachesHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHIV/AIDSJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSkin RashStrokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcerNone
Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.
Patient Signature and/or Responsible Party*

Clear
Date*

MonthDayYear
Date
Authorization For Medical Records Release

To Request Release Of Medical Information Please Complete And Sign This Form
I hereby voluntarily authorize the disclosure of information from my health record.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Record Number
Date of Birth

MonthDayYear
Date
Information Requested
Purpose of Release
THE INFORMATION IS TO BE PROVIDED TO
Name of Person/Facility/Organization
Phone Number
Please enter a valid phone number.
PLEASE SIGN BELOW TO COMPLETE THE FORM
Name of Patient or Patient Representative
Relationship to Patient
This information is to be released for the purpose stated above and may not be used by the recipient for any other purpose. Under HIPAA with a patient's written request, records must be provided within 30 days of a request.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Adult New Patient Form

Spouse/Emergency Contact Information

Dental Insurance Information

Dental History

Medical History

Authorization

Authorization For Medical Records Release