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
2 digit month, 2 digit day, 4 digit yearDate
Patient's Name

First NameLast Name
Patient's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Patient's Age
Patient's Gender
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
E-mail
Home Phone Number
Format: (000) 000-0000.
Mobile Phone Number
Format: (000) 000-0000.
Work Phone Number
Format: (000) 000-0000.
Are there other family members seen by us? If so, please list:
Whom may we thank for referring you?

Other
Patient’s interests and hobbies:

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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearBirthday Date
Employer Name
2.) Second Insurance Company Name (If applicable)
Group #
ID #
Subscribers Name
Subscribers Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearBirthday Date
Do you have coverage through:
I consent to Towne Square Orthodontics submitting a predetermination or calling my insurance company to inquire into orthodontic coverage.

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.
Your Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

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
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Should be Empty:

Rows	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