New Patient Information Form

New Patient Information Form
Date

MonthDayYear
Date
Name

First NameLast Name
Nickname
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (for Appointment Reminders)
Please enter a valid phone number.
Other Phone Number
Please enter a valid phone number.
Email (for Appointment Reminders)
example@example.com
Birthdate

MonthDayYear
Date
Age
Sex
School/Employer
Grade/Position
Interests/Sports
Musical Instruments Played
Responsible Party Information

Primary denotes the person with the Primary Insurance Coverage
Primary Party
Marital Status
Title
Name

First NameLast Name
DOB

MonthDayYear
Date
Social Security #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Employer
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you worked there?
Work Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Insurance Carrier
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Phone
Please enter a valid phone number.
Group #
Member/Subscriber ID #
Secondary Party
Marital Status
Title
Name

First NameLast Name
DOB

MonthDayYear
Date
Social Security #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Employer
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you worked there?
Work Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Insurance Carrier
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Phone
Please enter a valid phone number.
Group #
Member/Subscriber ID #
Other Responsible Parties
Dentist
Last Cleaning Visit

MonthDayYear
Date
Whom may we thank for referring you to our office?
How did you hear about us?
Reason for Consultation
Patient Medical History
Please select all related to the patient's medical history

AIDS/HIV+Alcohol/Drug AbuseAnemiaArtificial JointsArtificial ValveArthritisAsthmaAutoimmuneBleeding DisordersBulimiaCancerCerebral PalsyChemotherapyChest PainsCongenital DefectDiabetesDown SyndromeEndocrine ProblemsEmotional DisordersEpilepsyDizziness, FaintingGlaucomaHandicap/DisabledHeadachesHearing ProblemsHeart AttackHeart MurmurHeart ConditionHepatitis/Liver ProblemHigh Blood PressureHospitalizedImmune ProblemsJoint ReplacementKidney ProblemsLow Blood PressureMuscular DisordersChronic Neck PainNervous DisordersOrgan TransplantMitral Valve ProlapseMedical OperationsPneumoniaPregnantProlonged BleedingRadiation TreatmentRheumatic FeverScoliosisSeizures/ConvulsionsSinus ProblemsStrokeTuberculosisVenereal Disease
Please select any of the following allergies the patient may have:

NoneDrugsLatexMetalsPlasticsRubberSeasonal
Please select any of the following dental conditions the patient may have:

Jaw ClickingCold Sores/HerpesPainful ChewingPeriodontal ProblemsSpeech ProblemsTMJ ProblemsTooth GrindingUnfinished Dental Work
Please explain any selected items above:
Any other disease, problems, or allergies not listed above?
Please list all medications currently taken by the patient:
Female: Has she started menstruating?

YesNo
At what age?
Has the patient had their wisdom teeth extracted?

YesNo
Any face/mouth injuries?

YesNo
Any missing teeth?

YesNo
Does the patient normally breathe through their mouth while awake or asleep?

YesNo
Does the patient's gums bleed while brushing or flossing?

YesNo
Has the patient undergone any previous orthodontic treatment?

YesNo
Have other orthodontists been consulted?

YesNo
Are there any oral habits past or present (thumb or finger sucking, pacifier, mouth breathing, etc.)?

YesNo
Has the patient's adenoids and tonsils been removed?

YesNo
Any oral concerns?
Please list the names and ages of any siblings the patient may have:
Would you like us to see anybody else in your family?
The undersigned hereby authorizes Dr. Ragan and/ or his staff to perform the examination including x-rays, photos, and study models. I authorize the discussion and/ or consultation of the provided information, examination, and records with dentists, dental specialists, and other health care professionals as needed.

Orthodontic appliances are composed of very small parts that could be accidentally swallowed, aspirated (inhaled), impacted and could irritate or damage the oral tissues. If unsure of the location or if the object is inhaled or ingested, a chest x-ray may be required to isolate the object. The undersigned authorizes all forms of treatment including separators, bands, and braces with knowledge and understanding of the risks. This shall remain in force and effective until canceled by either party. All fees for services rendered are due at the conclusion of each appointment unless other financial arrangements have been made.
Signature

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Date

MonthDayYear
Date
Name

First NameLast Name
Relationship to Patient
Should be Empty:

New Patient Information Form

Responsible Party Information

Patient Medical History