New Patient Information Adult

Welcome to Our Practice
ADULT PATIENT INFORMATION
Patient's Name
Nickname
Gender

Male Female
Age
Birthdate

Month Day Year
Date
Address

Address

Street Address Line 2

City/State

Zip
Cell Phone #
Cell Carrier
Email Address
example@example.com
Have you had previous orthodontic consultations?

Yes No
Have you had previous orthodontic treatment?

Yes No
Doctor's name
What is it about your teeth/bite/smile that has brought you to see us?
Who may we thank for referring you to Kragor Orthodontics?
How would you like to receive your Appointment Reminders?

Email Both Text Message
Social Security #
Birthdate

Month Day Year
Date
Employer
Occupation
Spouse's Name (if applicable)
Social Security #
Birthdate

Month Day Year
Date
Cell Phone
Email Address
example@example.com
Employer
Occupation
Name of nearest relative not living with you/ Emergency Contact
Contact #
Work #
Address

Address

Street Address Line 2

City/State

Zip
Patient's Dentist
Patient's Last Dental Visit
Has patient had any unfavorable dental experiences?
Please check the box (s) if applicable

Missing permanent teeth not due to extraction Lip Sucking / Lip biting Periodontal Disease Nursing/Bottle Habits Thumb Sucking/ Finger ASucking Nail Biting
MEDICAL INFORMATION
Excellent

Patient's Overall Health Good Poor
Is patient currently under the care of a doctor?

Yes No. If yes, what for
If yes, what for
Is patient currently taking any medication?

Yes No. If yes, what for?
Yes, what for?
Has patient ever been hospitalized?

Yes No. If yes, what for?
If yes, what for?
Does the patient currently have, or has the patient ever had any of the following?
Please check the box (s) if applicable.

Diabetes Heart Murmur Cancer Rheumatic Fever HIV/AIDS Congenital Heart Defect Convulsions/Epilepsy Abnormal Bleeding Hearing Impairment Any Operations Prosthesis Asthma Hepatitis Hemophilia Tuberculosis Scarlet Fever Kidney/ Liver Problems Handicap/ Disabilities Allergy to Latex Allergies to Food Allergy to Nickel Allergy to Any Medications Any Stays in Hospital
Please discuss any serious medical conditions the patient has/had
I understand 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 my child's medical status.
Print Patient Name
Patient Signature

Clear
Date

Month Day Year
Date
I verbally reviewed the medical/dental information above with the patient named herein.
Signature

Clear
Date

Month Day Year
Date
Doctor's Comments
1816 Eagle Drive, Woodstock, GA 30188
Should be Empty:

Welcome to Our Practice

ADULT PATIENT INFORMATION

MEDICAL INFORMATION