New Patient Form - Hage Orthodontics

New Patient Form - Hage Orthodontics
Submit your health history form online to your orthodontist today.

Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form and click "submit". Your information will be sent to our office with secure encryption. We will have your information when you arrive for your first appointment.
Patient Information
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone*
Please enter a valid phone number.
Birthdate*

MonthDayYear
Date
Marital Status*
Sex*
Email
example@example.com
If patient is a minor, parent's / guardian's name
If patient is a minor, name and ages of siblings
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
Relationship to Patient*
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Marital Status
Home Phone
Please enter a valid phone number.
Birthdate

MonthDayYear
Date
Have you been at this address longer than 3 years?*

YesNo
Previous Address

Street Address

Street Address Line 2

CityState

Zip Code
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Social Security #
Employer
Occupation
Number of years employed
Is there an additional responsible party for this account?*

YesNo
Relationship to Patient
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Marital Status
Have you been at this address longer than 3 years?

YesNo
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Social Security #
Birthdate

MonthDayYear
Date
Employer
Occupation
Number of years employed
Dental Insurance Information
Insured's Name
Insured's Birthdate

MonthDayYear
Date
Social Security #
Insurance Company
Group Number
Phone
Please enter a valid phone number.
Insurance Company Address

Street Address

Street Address Line 2

CityState

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 #
Phone
Please enter a valid phone number.
Insurance Company Address
Insured's Employer
Subscriber / Employee ID #
Emergency Information
Name of nearest relative not living with you*
Relationship*
Cell or Phone*
Please enter a valid phone number.
Complete Address*

Street Address

Street Address Line 2

CityState

Zip Code
What are the main concerns that you would like orthodontics to address?
Please describe concerns*
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 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 his/her teeth daily?*

YesNo
Floss his/her teeth daily?*

YesNo
Patient's Dentist*
Phone
Please enter a valid phone number.
Date of Last Visit

MonthDayYear
Date
Patient's Physician*
Phone
Please enter a valid phone number.
Is the patient currently under the care of a physician?*

YesNo
If patient is a minor, has puberty begun?*

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

GoodFairPoor
Do you take or have you taken an osteoporosis medication?*

YesNo
Please list all drugs that the patient is currently taking
Please list all allergies (drugs, foods, other)
Has the patient ever had any of the following medical problems?
Abnormal Bleeding*

YesNo
ADD / ADHD*

YesNo
Sleep Apnea*

YesNo
Allergy to Latex / Metals*

YesNo
Allergy to Plastic*

YesNo
Any Hospital Stays*

YesNo
Any Operations*

YesNo
Asthma*

YesNo
Cancer*

YesNo
Congenital Heart Defect*

YesNo
Convulsions / Epilepsy*

YesNo
Diabetes*

YesNo
Handicaps / Disabilities*

YesNo
Hearing Impairment*

YesNo
Heart Murmur*

YesNo
Hemophilia*

YesNo
Hepatitis*

YesNo
HIV+ / AIDS*

YesNo
Kidney / Liver Problems*

YesNo
Psychological Counseling*

YesNo
Rheumatic / Scarlet Fever*

YesNo
Tuberculosis (TB)*

YesNo
Does / Has the patient have/had any of the following habits?
Chew/Smoke Tobacco*

YesNo
Yes No Clenching/Grinding Teeth*

YesNo
Lip Sucking / Biting*

YesNo
Mouth Breather*

YesNo
Nail Biting*

YesNo
Nursing Bottle Habits*

YesNo
Speech Problems*

YesNo
Thumb / Finger Sucking*

YesNo
Tongue Thrust*

YesNo
Signatures
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 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 acknowledgements above.
Signature

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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 - Hage Orthodontics

Patient Information

Person Responsible For Account

Dental Insurance Information

Emergency Information

What are the main concerns that you would like orthodontics to address?

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

Does / Has the patient have/had any of the following habits?

Signatures