New Patient Registration & Health History

New Patient Registration & Health History
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Parent/Guardian Name - if the patient is younger than the age of 18.

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Does the phone # above receive text messages?*
Email
example@example.com
Preferred Method of Contact:*
Referral Source*
If other, please specify below
Do you have or had in the past any friends or family in treatment with Dr. VanLue?
Who may we thank for referring you to our office?
Name of Friend, Family member, or Doctor
Dental Concerns/Questionaire
I don't like:*

My smileThe crowding of my teethThe spaces between my teethThe way my teeth fit togetherMy overbiteMy underbiteMy missing teethThe size/shape of my teethThe color of my teethNone of the above
Any specific concerns or questions not listed above?
Do you have any funny clicking, popping, or cracking when you open or close your mouth?*
Does your jaw ever lock open or closed?*
Have you ever been seen by an orthodontist?
Is there any particular type of orthodontic treatment that you are interested in? (Choose 1 or more)*

Metal BracesCeramic/Clear BracesInvisalignFastest TreatmentLeast noticeableI don't know
Patient's readiness/desire to start: (on a scale of 1-5)
Who is your general dentist?
Have you had a dental exam within the last year?*
Have you had a dental cleaning within the last 6 months?*
Have you ever been diagnosed to have periodontal disease?*
Have you been diagnosed with any dental treatment needs that have not been completed?*
(Cavity fillings, crowns, cleaning, etc. If no, type NONE).
Dental/Medical Health History

The answers are for office records only and will be considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation
Do you have any allergies?*
If yes, please specify in the field above. If no, type NONE.
Are you currently taking any medications?*
If yes, please specify in the field above. If no, type NONE.
Are you taking or have you ever taken Bisphosphonates for osteoporosis?*

YESNO
Do you have any medical conditions that we should be aware of? (Communicable diseases, cardiovascular problems, diabetes, etc.)*
If yes, please specify in the field above. If no, type NONE.
Insurance
If you would like us to verify dental insurance you may have prior to your consultation, please provide a clear picture of the front and back of your PRIMARY DENTAL Insurance card. We will be happy to let you know if your insurance will cover any portion of your orthodontic treatment cost.
Is there any Insurance we can check on for you?*

YESNO (if no, skip to the Acknowledgment section)
Name of Insured on Primary Insurance

First NameLast Name
Date of Birth of Insured

MonthDayYear
Date
Subscriber Member ID # or SSN#
Phone Number of Insured if different from above

Area CodePhone Number
Relationship to Patient
Type SELF if you're the patient
Is this an Employer Policy?

YESNO
Employer Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number

Area CodePhone Number
Group #, if any
Name of Insurance Company
Insurance Company Phone Number

Area CodePhone Number
Photo Upload 1 - Front of your Primary Dental Insurance Card

Browse Files

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Photo Upload 2 - Back of your Primary Dental Insurance Card

Browse Files

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Photo Upload 3 - Front of your Secondary Dental Insurance Card (if applicable)

Browse Files

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Photo Upload 4 - Back of your Secondary Dental Insurance Card (if applicable)

Browse Files

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Acknowledgement
I acknowledge that all information I provided in this form is true and accurate to the best of my knowledge. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status, I will so inform this practice.
Signature*

Clear
Printed Name*

First NameLast Name
Date Signed*

MonthDayYear
Date
Relationship to Patient*
Type SELF if you are the patient
FOR OFFICE USE ONLY

Patient Health History has been reviewed by the TC and Dr. VanLue
TC has reviewed

Clear
Treatment Coordinator
Date

MonthDayYear
Date
Dr. VanLue has reviewed

Clear
Dr. Jason VanLue
Date

MonthDayYear
Date
Should be Empty:

New Patient Registration & Health History

Dental Concerns/Questionaire

Dental/Medical Health History

Insurance

Acknowledgement

FOR OFFICE USE ONLY