New Patient Form
Patient's Full Name:
*
Patient's Preferred Name:
Patient Gender:
*
Male
Female
Patient's Birthdate:
*
-
Month
-
Day
Year
Date
Patient's Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Email Address:
example@example.com
Patient's General Dentist:
Date of Last Dental Visit:
-
Month
-
Day
Year
Date
Has the patient had an orthodontic consult or treatment?
Yes
No
If so, when?
-
Month
-
Day
Year
Date
What is the main orthodontic concern?
Patient's School or Work:
What activities do you enjoy?
How did your hear about our office?
How did you hear about our office? (Please check all that apply)
Referred by Dentist
Google
Social Media
Location/Drive-By
Mailing
Magazine
Friend/Family Member
Fair/Community Event
Other
Billing Party Information
(Person financially responsible for making payments)
Same as Patient Information
Billing Party's Full Name:
*
Billing Parties Relationship to Patient:
*
Billing Party's Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Billing Party's Cell Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Billing Party's Work Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Billing Party's Email Address:
*
example@example.com
Marital Status:
Single
Married
Widowed
Separated
Divorced
Dental Insurance Information
If you have Orthodontic insurance, please provide the following information so we can verify your benefits before your scheduled appointment.
Policy Holder's Full Name:
Policy Holder's Date of Birth:
-
Month
-
Day
Year
Date
Name of Insurance Company:
Insurance Company Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Policy Holder's Social Security or Member Identification #:
Group Number:
Policy Holder's Employer:
Medical History
Physician's Name:
*
Physician's Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Has the patient ever had any of the following medical concerns?
*
Rows
Yes
No
Prolonged Bleeding/Transfusion
Artificial Bones / Joints / Valves
Arthritis
Asthma
Cancer / Chemotherapy
Congenital heart defects
Diabetes
Drug Abuse
Epilepsy / Seizures / Fainting
Fever Blisters / Herpes
Heart Attack / Stroke
Heart Murmur
Heart Surgery / Pacemaker
Hemophilia
Hepatitis
High / Low Blood Pressure
HIV+ / AIDS
Hospitalized for Any Reason
Kidney Disease
Mitral Valve Prolapse
Psychiatric Problems
Radiation Treatment
Rheumatic / Scarlet Fever
Sickle Cell Disease / Traits
Sinus Problems
Tuberculosis/Lung Disease
NO MEDICAL CONCERNS
If any of the above medical questions were answered "Yes," please explain:
Does the patient need to be pre-medicated prior to any dental procedures?
*
Yes
No
Is the patient allergic to any medications?
*
Yes
No
If "Yes," please list:
Is the patient allergic to any materials such as latex or nickel?
*
Yes
No
If "Yes," please list:
Is the patient allergic to any foods?
*
Yes
No
If "Yes," please list:
Please list any medications being taken by the patient and reason:
Additional Medical Concerns:
For Women
Are you pregnant?
Yes
No
Emergency Contact Information
Emergency Contact's Name
*
Emergency Contact's relationship to patient:
*
Emergency Contact's Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Responsible Party Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: