New Patient Form

New Patient Form
Patient Information

Please complete all of the information requested.
Date

MonthDayYear
Date
Nickname
Patient Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
D.O.B.

MonthDayYear
Date
Sex
Email
example@example.com
Family Dentist
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dentist Phone
Please enter a valid phone number.
Last Visit

MonthDayYear
Date
School
Whom may we thank for referring you to our office?
Is there another family member we have treated?
Responsible Party Information
Name

First NameLast Name
Marital Status
Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Previous Address (if less than 3 years)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email
example@example.com
Social Security Number
D.O.B.

MonthDayYear
Date
Relationship to Patient
Employer
Occupation
Number of Years Employed
Parent or Spouse's Name

First NameLast Name
Relationship to Patient
Employer
Occupation
Number of Years Employed
Social Security Number
D.O.B.

MonthDayYear
Date
Work Phone
Please enter a valid phone number.
Insurance Information
YesNo
YesNo
Insured's Name

First NameLast Name
Insured's Social Security Number
Insurance Company
Group #
Employee ID
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone
Please enter a valid phone number.
Insured's Name

First NameLast Name
Insured's Social Security Number
Insurance Company
Group #
Employee ID
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone
Please enter a valid phone number.
Medical History
YesNo
YesNo

Has the patient been treated for any of the following conditions?*

Rows	Yes	No
Hepatitis
AIDS
Diabetes
Rheumatic Fever
Asthma
Kidney Problems
Prolonged Bleeding
Tuberculosis

YesNo
YesNo
BothTonsils OnlyAdenoids Only
At what age?
YesNo
List any drugs or medications now being taken and for what purpose(s):
List any allergies or drug sensitivities:
Name of Personal Physician
The next three questions are for children and adolescent patients only.
YesNo
SlowMediumFast
Please provide the Height of:
Patient Height
Mother Height
Father Height
In your own words, why are you seeking orthodontic care (what do you think is the problem)?
Dental History
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Please specify:
At what age did the habit stop?
YesNo
YesNo
Name of Emergency Contact
Emergency Contact Phone
Please enter a valid phone number.
Signature of Custodial Parent or Guardian
Date

MonthDayYear
Date
Should be Empty:

New Patient Form

Patient Information

Responsible Party Information

Insurance Information

Medical History

Dental History