Welcome to the Orthodontist

Westside Orthodontics

Adult New Patient Form
Please bring your Dental Insurance Card to your exam appointment,
or print one off of your insurance company's website.
Name*

FirstLast
Birthdate

MonthDayYear
Age of Patient

ChildAdult
Email Address*
Best Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Spouse's Name

First NameLast Name
Birthdate

MonthDayYear
Address (if different from patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Best Phone Number

Area CodePhone Number
Physician
Physician Phone Number

Area CodePhone Number
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dentist
Dentist Phone Number

Area CodePhone Number
Dentist Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Whom may we Thank for referring you?
Person Responsible for Account
Medical History
Height
Weight
General Health

Have you ever had any of the following medical problems?

	Yes	No
Adenoids (removed)
Allergies
Any Operations
Diabetes
Epilepsy
Heart Disorders
HIV +/AIDS
Rheumatic / Scarlet Fever
Blood Disorders
Measles
Healing Ability (poor)
Hospitalized for Sickness or Injury
Injuries
Is Patient under Treatment at this time
Medication now being taken
Mumps
X-ray Treatment (Not Diagnostic)
Chicken Pox
Congenital Heart Defect
Handicaps/Disabilites

If you have/had any other medical issues not listed above, please describe.
Please Describe any Problems that concern you Orthodontically
Is patient covered by dental insurance?

YesNo
If yes, which carrier?*
Is patient covered by secondary dental insurance?

YesNo
If yes, which carrier?
Has the patient had previous orthodontics consultations or treatments?

YesNo
Doctor's Name

First NameLast Name
If so, on what date?
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 agree to the above terms and conditions*

YesNo
Should be Empty:

Medical History