New Patient Form

New Patient Form
Patient Information
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Birthdate*

MonthDayYear
Date
Marital Status
Sex
If Patient is a minor, Parent/Guardian's name:
Name & Ages of Siblings
Email
example@example.com
Whom may we thank for referring you to our office?
Sports/Hobbies/Musical Instruments
School/Occupation
Current Grade
Nickname
Person Responsible for Account
Same as above?*

YesNo
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you been at this address longer than 3 years?*

YesNo
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Birthdate

MonthDayYear
Date
Marital Status
Relationship to Patient*
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Social Security #
Employer
Occupation
No. of Years Employed
Dental Insurance Information
Insured's Name
Insured's Birthdate

MonthDayYear
Date
Social Security #
Insurance Company
Group No.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured's Employer
Subscriber/Employee ID #
Do you have dual coverage?*

YesNo
Insured's Name
Insured's Birthdate

MonthDayYear
Date
Social Security #
Insurance Company
Group No.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured's Employer
Subscriber/Employee ID #
Emergency Information
Name of nearest relative not living with you:*
Relationship*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Orthodontic Concerns
What are the main concerns that you would like orthodontic treatment to address?*
Has the patient ever been evaluated for or had orthodontic treatment before?*

YesNo
Have there been any injuries to the face, mouth, teeth, or chin?*

YesNo
How does the patient feel about wearing orthodontic appliances?
Have the adenoids or tonsils been removed?*

YesNo
Has the patient been informed of any missing or extra permanent teeth?*

YesNo
Has the patient ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?*

YesNo
Does the patient brush their teeth daily?*

YesNo
Does the patient floss their teeth daily?*

YesNo
Patient's Dentist*
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Last Visit

MonthDayYear
Date
Patient's Physician*
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is the patient currently under the care of a physician?*

YesNo
Has puberty begun?*

YesNo
If yes, when?
Please describe the patient's current physical health:*

GoodFairPoor
Does the patient take or have they taken an osteoporosis medication?*

YesNo
Please list all medications the patient currently takes:
Please list all allergies of the patient:

Has the patient ever had any of the following medical problems?*

Rows	Yes	No
Abnormal Bleeding
ADD/ADHD
Sleep Apnea
Allergy to Metals/Latex
Allergy to Plastic
Any Hospital Stays
Any Operations
Asthma
Cancer
Congenital Heart Defect
Convulsions/Epilepsy
Diabetes
Handicaps/Disabilities
Hearing Impairment
Heart Murmur
Hemophilia
Hepatitis
HIV+/AIDS
Kidney/Liver Problems
Psychological Counseling
Rheumatic/Scarlet Fever
Tuberculosis (TB)

Please discuss any other medical conditions not mentioned above:

Does/has the patient had any of the following habits?*

Rows	Yes	No
Chew/Smoke Tobacco
Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail Biting
Nursing Bottle Habits
Speech Problems
Thumb/Finger Sucking
Tongue Thrust

I understand that 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 the patient's medical status. I authorize the dental staff to perform the necessary dental services I/my child may need.This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting agencies.If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.I understand that at the time of my office visit, my physical signature will be required to confirm the acknowledgments above.
Signature
The Parent or Guardian who accompanies the child is responsible for payment. Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.

Please check your form to make sure it is complete and press the submit button when you are done. You will see a confirmation page when your form has been successfully submitted. Thank you!
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New Patient Form

Patient Information

Person Responsible for Account

Dental Insurance Information

Emergency Information

Orthodontic Concerns