Chapel Hills New Patient Form

Patient Information:

(Please fill in the below information about the patient to be seen at our office.)

Name*

First NameLast Name

Nickname

Sex

Age

Birth Date

Date

Patient Full Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Number

Area CodePhone Number

Cell Number

Area CodePhone Number

Who's Number

Email (parents email if minor)

example@example.com

Whom may we thank for referring you to us?

If other please specify

School/Employer

Grade/Position

Interests/Sports

Names of Brothers and Sisters, Age

Reason for Consult

Primary Guardian (Not Insurance)

First Name

Last Name

Relationship to Patient?

If Other, please specify

Telephone

Area CodePhone Number

Full Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer

Telephone

Area CodePhone Number

Social Security*

Secondary Guardian (not insurance)

Name

First NameLast Name

Relationship to Patient?

If Other, please specify

Full Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Telephone

Area CodePhone Number

Employer

Work Number

Area CodePhone Number

Social Security

Insurance Information

(please fill out the form completely so we may properly file your insurance)

PRIMARY: Insurance Carrier and Address:

Policy Holders Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Policy Holder Birthday

Date

Phone Number

Area CodePhone Number

Social Security Number

Primary Health Information

Present Dentist

Dentists Number

Area CodePhone Number

Date of Last Visit

Date

Have wisdom teeth been extracted

If yes when?

Do gums bleed when brushed or flossed?

Have tonsils and adenoids been removed?*

Any face, mouth or teeth injuries?

Have you had previous orthodontic treatment?

Has an orthodontist been consulted previously?

If yes, When?

Date

Are there any missing or extra teeth?

HIV +/AIDS*

YesNo

Allergy to Latex*

YesNo

Anemia*

YesNo

Arthritis*

YesNo

Asthma

YesNo

Autoimmune*

YesNo

Bone Disorders*

YesNo

Bullimia*

YesNo

Breathing Problems/Sinus Issues*

YesNo

Cancer*

YesNo

Cerebral Palsy*

YesNo

Chest Pain*

YesNo

Chronic Neck Pain*

YesNo

Clicking of Jaw*

YesNo

Cold Sores/Herpes*

YesNo

Diabetes*

YesNo

Down Syndrome*

YesNo

Drug Allergies*

YesNo

If yes, Please Specify.

Endocrine Problems*

YesNo

Emotional Disorders*

YesNo

Epilepsy*

YesNo

Fainting/Dizziness*

YesNo

Glaucoma*

YesNo

Headaches*

YesNo

Heart Condition*

YesNo

Hepatitis*

YesNo

High Blood Pressure*

YesNo

Immune Problems*

YesNo

Kidney/Liver Problems*

YesNo

Low Blood Pressure*

YesNo

Mouth Breathing*

YesNo

Muscular Disorder*

YesNo

Nervous Disorder*

YesNo

Organ Transplant*

YesNo

Painful Chewing*

YesNo

Periodontal Problems*

YesNo

Pneumonia*

YesNo

Pregnant*

YesNo

Prolonged Bleeding*

YesNo

Rheumatic /Scarlet Fever*

YesNo

Scoliosis*

YesNo

Seizures*

YesNo

Sicca*

YesNo

Speech Problems*

YesNo

TMJ Problems*

YesNo

Tooth Grinding*

YesNo

Tuberculosis (TB)*

YesNo

Thumb Habit*

YesNo

Osteoporosis*

YesNo

Any disease, problems, or allergies not mentioned above?

List medication currently taking:

Female Teens:

Have you started menstruating?

YesNo

At what age?

Are you aware that some appointments will be during work/school hours:

Benefits and Limitations

Orthodontics is a service that provides an improvement in the appearance of the teeth, in general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and may have an atypical response to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of the teeth and some change after treatment. I understand that my diagnostic records may be used for educational and training purposes. I have truthfully answered all the above questions and agree to inform this office of any change in my medical or dental history. In addition, I authorize Chapel Hills Orthodontics to perform a complete orthodontic evaluation.

Signature of Responsible Party

Relationship to Patient

Date

We would like to welcome you to our office.

Primary Health Information