Adult New Patient Information

Adult New Patient Information
Patient Name*

First NameLast Name
Gender
Social Security Number
Birthdate

MonthDayYear
Date
Driver's License Number
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Employer
Occupation
Spouse/Emergency Contact Information
Marital Status
Emergency Contact's Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relation to You
Spouse/Partner's Name

First NameLast 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 child.
Relation to Patient
Insurance Information
Primary Insurance Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Group Number
Policy Number
Member ID Number
Policy Holder's Name
Relation to Patient
Policy Holder's Social Security Number
Policy Holder's D.O.B.

MonthDayYear
Date
Employer
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Co-Pay (if known)
Deductible (if known)
Secondary Insurance Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Group Number
Policy Number
Member ID Number
Policy Holder's Name
Relation to Patient
Policy Holder's Social Security Number
Policy Holder's D.O.B.

MonthDayYear
Date
Employer
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Co-Pay (if known)
Deductible (if known)
Dental History
General Dentist
Last Visit

MonthDayYear
Date
How did you hear about our practice?
Name of Person Referring (if applicable)
What are the main concerns you would like orthodontics to accomplish?
Have you visited an orthodontist before?

YesNo
When? For What Reason(s)?
Have your tonsils or adenoids been removed?

YesNo
Do you have any missing or extra permanent teeth?

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

TeethMouthChin
Do you have any speech problems?

YesNo
If so, explain:
Do you currently or have you ever had any of the following habits?

Clenching/Grinding TeethLip Sucking/BitingMouth BreathingNail BitingThumb/Finger SuckingChewing/Eating Problems
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?

YesNo
Do you take antibiotic pre-medication before any dental procedures?

YesNo
Medical History
Are you currently being treated by a physician?

YesNo
Reason
Physician
Last Visit

MonthDayYear
Date
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Do you have any allergies/sensitivities to medications or latex?

YesNo
If yes, please list allergies:
Are you currently taking any prescription or over-the-counter medications?

YesNo
If yes, please list with the dosage:
Have you had any serious illnesses or operations? If yes, describe:
Have you ever had a blood transfusion?

YesNo
If yes, give approximate dates:

MonthDayYear
Date
Are you pregnant?

YesNo
Are you nursing

YesNo
Are you taking birth control pills?

YesNo

Do you have or have you ever had any of the following:

Rows	Yes	No
Anemia
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back Problems
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Cortisone Treatments
Cough, Persistent
Coughing Blood
Diabetes
Epilepsy
Fainting
Glaucoma
Headaches
Heart Murmur
Heart Problems
Hemophilia
Hepatitis
High Blood Pressure
HIV/AIDS
Jaw Pain
Kidney Disease
Liver Disease
Mitral Valve Prolapse
Pacemaker
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Skin Rash
Stroke
Swelling of Feet or Ankles
Thyroid Problems
Tobacco Habit
Tonsillitis
Tuberculosis
Ulcer
Venereal Disease

Preferred Office

NorfolkVirginia BeachChesapeake
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
Date

MonthDayYear
Date
Should be Empty:

Adult New Patient Information

Spouse/Emergency Contact Information

Insurance Information

Dental History

Medical History

Authorization