Adult New Patient Form

Adult New Patient Form
How'd you hear about us?
About You
Today's Date*

MonthDayYear
Date
Email Address*
example@example.com
Name*

PrefixFirst NameLast Name
Preferred Name*
Email
example@example.com
Gender*
Date of Birth*

MonthDayYear
Date
Age*
SSN
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status*
Home Phone*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Employer*
How long have you been there?*
Occupation*
Where & when are the best times to reach you?*
Whom may we thanks for referring you to our office?*
Other family members seen by us:*
Previous/Present Dentist*
Person Responsible for Account*
Orthodontic Insurance

Primary
Do you have Orthodontic Coverage?

YesNo
Do you have Dental Coverage?

YesNo
Insurance Company Name
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone
Please enter a valid phone number.
Group # (Plan, Local or Policy #)
Insured's Name
Relationship to Patient
Insured's Date of Birth

MonthDayYear
Date
Insured's SSN
Insured's Employer
Orthodontic Insurance

Secondary
Do you have Orthodontic Coverage?

YesNo
Do you have Dental Coverage?

YesNo
Insurance Company Name
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone
Please enter a valid phone number.
Group # (Plan, Local or Policy #)
Insured's Name
Relationship to Patient
Insured's Date of Birth

MonthDayYear
Date
Insured's SSN
Insured's Employer
Payment is due in full at the time of treatment unless prior arrangements have been approved.

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 hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office. I understand that I am responsible for all costs of orthodontic treatment. I hereby authorize the release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.
Signature*

Clear
Date

MonthDayYear
Date
Medical History
Do you have a personal physician?*

YesNo
Physician's Name/Practice*
Phone Number*
Please enter a valid phone number.
Date of Last Visit*

MonthDayYear
Date
My current physical health is:*
Are you currently under the care of a physician?*

YesNo
Please explain:
Do you smoke or use tobacco in any other form?*

YesNo
Have you had any metal rods, pins or implants?*

YesNo
Are you taking any prescription/over-the-counter drugs?*

YesNo
Have you ever taken Phen-Ren/Redux/Pondimin?*

YesNo
If so, when?*

Have you ever had any of the following diseases or medical problems?*

	Yes	No
Abnormal Bleeding/Hemophilia
AIDS
Alcohol/Drug Use
Anemia
Arthritis
Artificial Bones/Joints/Valves
Asthma
Blood Transfusion
Cancer/Chemotherapy
Colitis
Congenital Heart Defect
Diabetes
Difficulty Breathing
Emphysema
Epilepsy
Fainting Spells
Frequent Headaches
Glaucoma
Hay Fever
Heart Attack/Surgery
Heart Murmur
Hepatitis
Herpes/Fever Blisters
High Blood Pressure
HIV
Hospitalized for Any Reason
Kidney Problems
Liver Disease
Low Blood Pressure
Lupus
Mitral Valve Prolapse
Pacemaker
Psychiatric Problems
Radiation Treatment
Rheumatic/Scarlet Fever
Seizures
Shingles
Sickle Cell Disease/Traits
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis (TB)
Ulcers
Venereal Disease

Please list any serious medical condition(s) that you have ever had that are not listed above:*

Are you allergic to any of the following?*

	Yes	No
Aspirin
Codeine
Dental Aesthetics
Erythromycin
Jewelry/Metals
Latex
Penicillin
Tetracycline
Other

Please list any other drugs/materials that you are allergic to:*
Dental History
What are the main concerns that you would like orthodontics to accomplish?*
Have you ever had or been evaluated for orthodontic treatment?*

YesNo
Have you ever had a serious/difficult problem associated with any previous dental work?*

YesNo
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)*

YesNo
My current dental health is...*
Do you still have your wisdom teeth?*

YesNo
Have you ever had an injury to your...*

MouthTeethChinNone
Do you have any speech problems?*
Do you generally breathe through your mouth?*

YesNo
Do you have any missing or extra permanent teeth?*

YesNo
Are you happy with the way your smile looks?*

YesNo
If not, what would you change?*
Are you actively being treated with another braces or Invisalign with another Orthodontist at this time?*
If yes, you need to stop by them and call the office to schedule.
Have you seen your general dentist for a cleaning and exam within the last 6 months?*
Name of the Dentist Office
Name of Dentist
Dentist Phone Number
Please enter a valid phone number.
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 confidence and that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent. 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 the office, use the services of one or more credit reporting services.
Signature*

Clear
Date

MonthDayYear
Date
Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
Date

MonthDayYear
Date
Should be Empty:

Adult New Patient Form

About You

Orthodontic Insurance

Orthodontic Insurance

Medical History

Dental History