Mogavero Orthodontics Adult New Patient Form

Mogavero Orthodontics Adult Patient Form

Information must be filled out completely
Name*

First NameLast Name
Marital Status*
birthdate

MonthDayYear
Date
E-mail*
General Dentist
Date of Last Visit

MonthDayYear
Date
Whom may we thank you for referring you to our office?
Other Family Members Seen by Us
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone #

Area CodePhone Number
Cell Phone #

Area CodePhone Number
Work Phone #

Area CodePhone Number
Employer Information
How Long There?
Occupation
Best Place to Reach You
Spouse Information
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Work Phone #

Area CodePhone Number
Cell Phone #

Area CodePhone Number
Home Phone #

Area CodePhone Number
Relation
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Name
Primary Orthodontic Insurance
Orthodontic Coverage

YesNo
Policy Holder's Name
Birthdate

MonthDayYear
Date
ID #
Relationship to Patient
Employer Name
Insurance Company
Insurance Company Phone #

Area CodePhone Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Group / Plan #
Secondary Orthodontic Insurance
Orthodontic Coverage

YesNo
Policy Holder's Name
Birthdate

MonthDayYear
Date
ID #
Relationship to Patient
Employer Name
Insurance Company
Insurance Company Phone #

Area CodePhone Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Group / Plan #
Medical History
Do you have a personal physician?

YesNo
Physician Name
Date of Last Visit

MonthDayYear
Date
Please describe your physical health

ExcellentGoodFairPoor
Please list all medications that you are currently taking and for what conditions
Please list any medications that you are currently allergic to
For Women:
Are you currently on a birth control pill?

YesNo
Are you pregnant?

YesNo
If yes, how many weeks?
Are you nursing?

YesNo
What are the main concerns you would like orthodontics to address?
Patient
Dentist
Have you ever been evaluated for orthodontic treatment before?
Have there been any injuries to the face, teeth, jaw, mouth or chin? Please Explain
Have adenoids or tonsils been removed?

YesNo
Have you been informed of any missing or extra permanent teeth?

YesNo
If yes, which ones?
Have you ever had any pain or tenderness in the jaw joint? (TMJ, TMD)?*

YesNo
Do you brush your teeth daily?*

YesNo
Do you floss your teeth daily?*

YesNo

Have you ever had any of the following medical issues?

	Yes	No
Any Hospital Stays
Allergies to any drugs, latex/metal or plastics?
Abnormal Bleeding
Any Operations
Asthma
Cancer

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
Rheumatic/Scarlet Fever*

YesNo
Tuberculosis (TB)*

YesNo
History of Endocarditis*

YesNo
Artificial valves including prosthetic material and devices*

YesNo
Heart transplant*

YesNo
Do you require antibiotic prophylaxis prior to your dental visit*

YesNo
If you have any other medical issues not listed above, please describe*
Please list an emergency contact not living with you
Name*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agree to Terms

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 also authorize Mogavero Orthodontics staff to perform the necessary orthodontic services as needed. I further authorize that photos taken during treatment may be used for professional consultations and are the property of our office. I understand that where appropriate, credit bureau reports may be obtained.

I agree to Terms of Service and Privacy Policy provided by Mogavero Orthodontics. By providing my phone number, I agree to receive text messages from Mogavero Orthodontics. I understand I can SMS opt-out at any time by responding "Stop."
I Agree to the above terms and conditions*

Yes
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Mogavero Orthodontics Adult Patient Form