Adult Patient Form
01: About You
Your Name:
*
First Name
Last Name
I prefer to be called:
Gender:
*
Male
Female
Birthday:
-
Month
-
Day
Year
Date
Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status:
*
Single
Married
Divorced
Widowed
Separated
Home Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
*
example@example.com
Social Security Number:
Employer:
Employer's Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long there?
Occupation
Where and when are the best times to reach you?
Whom may we thank for referring you?
Other family members seen by us:
General Dentist:
Last Visit Date:
-
Month
-
Day
Year
Date
02: Spouse Information
His/Her Name:
First Name
Last Name
Employer:
Work Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Social Security Number:
Birthdate:
-
Month
-
Day
Year
Date
Person Responsible for Account:
First Name
Last Name
Home Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Billing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship:
Social Security Number:
Employer:
Work Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Birthdate:
-
Month
-
Day
Year
Date
03: Orthodontic Insurance
Do you have orthodontic insurance?
*
Yes
No
Insurance Co. Name:
Insurance Co. Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Co. Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Group # (Plan, Local or Policy #)
Insured's Name:
First Name
Last Name
Relationship:
Insured's Birthday:
-
Month
-
Day
Year
Date
Insured's Social Security Number:
Insured's Employer:
Do you have secondary orthodontic insurance?
*
Yes
No
Secondary Insurance Co. Name:
Secondary Insurance Co. Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Insurance Co. Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Group # (Plan, Local or Policy #):
Insured's Name:
Relationship:
Insured's Birthday:
-
Month
-
Day
Year
Date
Insured's Social Security Number:
Insured's Employer
Emergency Contact Name:
First Name
Last Name
Emergency Contact Relationship:
Emergency Contact Work Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Home Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
04: Medical History
Do you have a personal physician?
*
Yes
No
Physician's Name:
Physician's Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Last Visit:
-
Month
-
Day
Year
Date
Your current physical health is:
*
Good
Fair
Poor
Are you taking any prescription/over-the-counter drugs?
*
Yes
No
If yes, please list each one:
Have you ever had any of the following diseases or medical problems?
Heart Attack/Stroke
Cancer/Chemotherapy
Heart Murmur
Rheumatic Fever
HIV+/AIDS
Heart Surgery/Pacemaker
Shingles
Mitral Valve Prolapse
Kidney Problems
Artificial Bones/Joints
Artificial Valves
Sinus Problems
High/Low Blood Pressure
Fever Blisters
Severe/Frequent Headaches
Psychiatric Problems
Epilepsy/Seizures/Fainting Spells
Diabetes/Tuberculosis
Drug/Alcohol Abuse
Venereal Disease
Hemophilia/Abnormal Bleeding
Ulcers/Colitis
Congenital Heart Defect
Anemia/Radiation Treatment
Asthma/Arthritis
Difficulty Breathing
Hospitalization for Any Reason
Hepatitis
Blood Transfusion
Emphysema/Glaucoma
Please list any medical condition(s) that you have ever had:
Are you allergic to any of the following items?
Penicillin
Aspirin
Erythromycin
Tetracycline
Dental Anesthetics
Codeine
Latex
Any Metal/Plastic
Other
Please list any other drugs that you are allergic to:
05: Dental History
What are the main concerns that you would like orthodontics to accomplish?
Have you ever had or been evaluated for orthodontic treatment?
*
Yes
No
Have you ever had a serious/difficult problem associated with any previous dental work?
*
Yes
No
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?
*
Yes
No
Your current dental health is:
*
Good
Fair
Poor
Do you like your smile?
*
Yes
No
Do your gums ever bleed?
*
Yes
No
Have you ever had an injury to your:
Mouth
Teeth
Chin
Do you have any speech problems?
Do you generally breathe through your mouth while awake?
Yes
No
Do you generally breathe through your mouth while asleep?
Yes
No
Do you have any missing or extra permanent teeth?
Yes
No
I understand that the information that I have given today is correct to the best of u knowledge. I also understand that this information will be held in the strictest confidence, and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services with my informed consent that I may need during diagnosis and treatment.
*
I understand and agree
This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services. Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
*
I understand and agree
Signature
*
Today's Date:
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: