ADULT - NEW PATIENT FORM

Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mobile Phone*

Area CodePhone Number
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Email*
example@example.com
Patient's Date of Birth*

MonthDayYear
Date
Who may we thank for referring you to our office?

First NameLast Name
Other family members and friends who have been seen by Dr. Paz's office
EMPLOYMENT INFORMATION
Employer or Company Name
Occupation
How long at current employer?
YOUR DENTIST'S INFORMATION
Your General Dentist

Doctor's First NameDoctor's Last Name
Your Dentist's Phone

Area CodePhone Number
Date of last appointment with your Dentist?

MonthDayYear
Date
Date of last X-rays taken?

MonthDayYear
Date
PRIMARY ORTHODONTIC INSURANCE

If you have orthodontic insurance, please fill out your information.
YesNo
Policy Holder's Name

First NameLast Name
Insurance
Name of Insurance Provider
Group/Plan Information
Group/Plan Number
Insured's ID Number
ID Number
Insurance Company Phone Number

Area CodePhone Number
Policy Holder's Date of Birth

MonthDayYear
Date
Policy Holder's Employment
Name of Employer
Insurance Company Address

Street Address

Street Address Line 2

CityState

Zip Code
MEDICAL & ORTHODONTIC HISTORY
YesNo
Physician's Name

First NameLast Name
Date of Last Visit

MonthDayYear
Date
ExcellentGoodFairPoor
Current Medications
Please list all medications currently being taken and for what condition(s) the medication is treating.
Medication Allergies
Please list all medications that you may be allergic to.
YesNo
SpacesCrowdingCosmeticBite is offCrossbiteMissing teethImpacted teethOrtho relapseFood impactionRetainer is brokenNeed new retainer/optionsLingual bonded retainer is brokenTMJ pain/jaw painBruxism/teeth grinding
Describe your DENTIST'S main concerns, if any:
Have you ever been evaluated by an orthodontist or have you had orthodontic treatment before?
Have you ever had injuries to the face, teeth, jaw, mouth, or chin?
Describe your injuries
MEDICAL ISSUES

Have you ever experienced any of these issues?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Do you have an allergy to any drug? If so, please decribe:
Please list any serious medical condition(s) you may have:
We respect limitations and extra patient care needed due to medical conditions. Please describe any medical or behavioral conditions that we should be aware of.
EMERGENCY CONTACT
Emergency Contact

First NameLast Name
Phone Number

Area CodePhone Number
TMJ Questionaire
Describe your jaw issues in your own words:
Left JawRight JawBoth sides
Do you have noise in your jaw? If so, when did you first notice it?
Left JawRight JawBoth Sides
If you have pain in or around your jaw, when did you first notice it ?
On a scale of 0-10, what is your pain level?
YesNo
YesNo
Are you taking any medication for this problem? If so, please list:
Did anything occur that might be related to the onset of this problem, such as trauma?
YesNo
YesNo
YesNo
GrindingClenching
MigraineHeadacheBoth
Has there been a recent change in your lifestyle, such as a change in marital status, childbirth, employment change, death in the family, or other stressful event?
Agree To Terms

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in patient's medical status. I also authorize the dental staff to perform the necessary orthodontic services as needed. I further authorize that photos taken during treatment may be used in journal articles or promotional materials and are the property of our office. I understand that where appropriate, credit bureau reports may be obtained.
YesNo
Should be Empty:

EMPLOYMENT INFORMATION

YOUR DENTIST'S INFORMATION

PRIMARY ORTHODONTIC INSURANCE

MEDICAL & ORTHODONTIC HISTORY

MEDICAL ISSUES

EMERGENCY CONTACT

TMJ Questionaire

Agree To Terms