Adult New Patient Form

Adult New Patient Form
Patient Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Age*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone No.*
Please enter a valid phone number.
Primary Phone Type*

HomeCell
Secondary Phone No.*
Please enter a valid phone number.
Secondary Phone Type*

HomeCell
E-mail Address*
example@example.com
How did you hear about our practice?*
Name of Person Referring (if applicable)
Employer's Name
Occupation
Spouse/Emergency Contact Information
Marital Status*

SingleMarriedDivorcedWidowedSignificant Other
Spouse/Partner's Name*
Emergency Contact Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person(s) OK to release appointment or medically related information to concerning you.*
Relation*
Dental Insurance Information
Primary Insurance Company*
Phone Number*
Please enter a valid phone number.
Group No.*
Policy No.*
Member ID No.*
Policy Holder's Name*
Policy Holder's Social Security Number*
Policy Holder's Birth Date*

MonthDayYear
Date
Employer*
Work Phone Number*
Please enter a valid phone number.
Co-pay (if known)*
Deductible (if known)*
Secondary Insurance Company*
Phone Number*
Please enter a valid phone number.
Group No.*
Policy No.*
Member ID No.*
Policy Holder's Name*
Policy Holder's Social Security Number*
Policy Holder's Birth Date*

MonthDayYear
Date
Employer*
Work Phone Number*
Please enter a valid phone number.
Co-pay (if known)*
Deductible (if known)*
Dental History
General Dentist*
Last Visit*
How did you hear about our Practice?*

AdInternetFamily or FriendPhysicianOther
Name of person referring (if applicable)
What are the main concerns you would like orthodontics to accomplish?*
Have you visited an orthodontist before?*

YesNo
Have your tonsils or adenoids been removed?*

YesNo
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?*

YesNo
Do you have any missing or extra permanent teeth?*

YesNo
Have you ever had an injury to (select all that apply)*

TeethMouthChinNo
Do you have speech problems?*

YesNo
Do your gums bleed?*

YesNo
Do you smoke?*

YesNo
Do you like your smile?*

YesNo
Do you currently or have you ever had any of the following habits?*

Clenching/Grinding TeethLip Sucking/BitingMouth BreathingNail bitingThumb/ Finger SuckingChewing/Eating ProblemsNone
Medical History
Are you currently being treated by a physician?*

YesNo
Do you have any allergies/sensitivities to medications or latex?*

YesNo
Are you currently taking any prescription or over-the-counter medications?*

YesNo
(WOMEN) Is the patient pregnant?*

YesNoN/A
Have you had any serious illnesses or operations? If yes, describe:*
Check if you have or have ever had any of the following*

AnemiaArthritis, RheumatismArtificial Heart ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseCancerChemical DependencyChemotherapyCirculatory ProblemsCortisone TreatmentsCough, PersistentCoughing BloodDiabetesEpilepsyFaintingGlaucomaHeadachesHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHIV/AIDSJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSkin RashStrokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcerNone
Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.
Patient Signature and/or Responsible Party*

Clear
Date*

MonthDayYear
Date
Authorization For Medical Records Release

To Request Release Of Medical Information Please Complete And Sign This Form
I hereby voluntarily authorize the disclosure of information from my health record.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Record Number
Date of Birth*

MonthDayYear
Date
Information Requested*
Purpose of Release*
THE INFORMATION IS TO BE PROVIDED TO
Name of Person/Facility/Organization*
Phone Number*
Please enter a valid phone number.
PLEASE SIGN BELOW TO COMPLETE THE FORM
Name of Patient or Patient Representative*
Relationship to Patient*
This information is to be released for the purpose stated above and may not be used by the recipient for any other purpose. Under HIPAA with a patient's written request, records must be provided within 30 days of a request.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Adult New Patient Form

Spouse/Emergency Contact Information

Dental Insurance Information

Dental History

Medical History

Authorization

Authorization For Medical Records Release