Towne Square Ortho - New Patient Form

PATIENT INFORMATION

To become acquainted and offer you the best patient care, we ask that you complete this information form.
Date*

MonthDayYear
Date
Patient's Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Patient's Age*
Patient's Gender*

MaleFemaleOther
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
E-mail*
Home Phone Number*
Mobile Phone Number
Work Phone Number
Are there other family members seen by us? If so, please list:
Whom may we thank for referring you?

DentistFriendFamily MemberWebsiteOther
Patient’s interests and hobbies:

Insurance Information
Employer Name
1.) Insurance Company Name
Group #
ID #
Subscribers Name
Subscribers Birthday

MonthDayYear
Birthday Date
Employer Name
2.) Second Insurance Company Name (If applicable)
Group #
ID #
Subscribers Name
Subscribers Birthday

MonthDayYear
Birthday Date
Do you have coverage through:

NIHBAISHSocial AssistanceWard of GovernmentCleft Palate Clinic
I consent to Towne Square Orthodontics submitting a predetermination or calling my insurance company to inquire into orthodontic coverage.*

I Agree

Appointment Cancellations
If you need to cancel or reschedule your appointment, we respectfully request at least 2 business days notice. Cancellations or missed appointments without 2 business days notice will result in a charge of $100.00.*

I understand the cancellation policy and authorize Towne Square Orthodontics to charge my credit card or process the deposit on file, if I fail to provide 2 business days notice.
Your Name*

First NameLast Name
Date*

MonthDayYear
Date

Authorization
I understand that the information provided today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and that it is my responsibility to inform the office of any changes in the medical condition of the patient. If you agree, please fill your full name below. *
Date*

MonthDayYear
Date
Name*

First NameLast Name
Should be Empty:

	Yes	No
Blood Transfusion/Hemophilia
AIDS/HIV
Anemia
Arthritis
Artificial Joints/Bones/Valves
Asthma
Cancer/Chemotherapy/Radiation Treatments
Colitis/Crohn's
Cystic Fibrosis
Congenital heart defect/Mitral Valve Prolapse
Diabetes
Difficulty Breathing
Emotional/Psychiatric Problems
Emphysema
Epilepsy/Seizures/Fainting
Fetal Alcohol Syndrome
Frequent Headaches
Glaucoma
Hay Fever
Hepatitis
Herpes
Heart Murmur
High Blood Pressure
Hospitalized for any reason
Kidney Problems
Liver Disease
Lupus
Rheumatic/Scarlet Fever
Shingles
Sickle Cell Disease/Traits
Tuberculosis
Ulcers
Venereal Disease

PATIENT INFORMATION