Adult New Patient Form

Adult New Patient Form
Date

MonthDayYear
Date
Patient's Name

First NameLast Name
Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Previous Address (if less than 3 years)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Birthdate

MonthDayYear
Date
Social Security #
Email
example@example.com
Marital Status
Employer
Occupation
Number of Years Employed
Spouse's Name

First NameLast Name
Relationship to Patient
Employer
Occupation
Number of Years Employed
Social Security #
Birthdate

MonthDayYear
Date
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Whom may we thank for referring you to our office?
Dental Insurance Information
Insured's Name

First NameLast Name
Social Security #
Insurance Company
Group Number
Local Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you have dual coverage?
Insured's Name

First NameLast Name
Social Security #
Insurance Company
Group Number
Local Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Information
Name of nearest relative not living with you
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I understand that, where appropriate, credit bureau reports may be obtained.
Signature
Date

MonthDayYear
Date
Medical History
Physician
Date of Last Visit

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you taking any medication?
Are you allergic to any medication?
Do you have a history of a major illness?
Have you had any operations?
Have you ever been involved in a serious accident?
Have you ever smoked or chewed tobacco?
Have you seen a physician in the last 12 months?
If you selected Yes to any of the above questions, please provide details:
For Female Patients Only
Are you pregnant?
Has menstruation started?
Select any of the medical conditions below that you have had or currently have:
Are there any medical conditions we have not discussed that you feel we should be aware of?
Dental History
General Dentist
Date of Last Visit

MonthDayYear
Date
What concerns you most about your teeth?
Are you presently in any dental pain?
Have you ever experienced any favorable reaction to dentistry?
Have your wisdom teeth been removed?
Have you ever lost or chipped any teeth?
Have there been any injuries to the face, mouth, or teeth?
Is any part of your mouth sensitive to pressure?
If Yes, where?
Is any part of your mouth sensitive to temperature?
If Yes, where?
Do your gums bleed when you brush?
Do you have any type of thumb or tongue habit?
Are you a mouth breather?
Have you ever seen an orthodontist?
If Yes, who and when?
What is your attitude toward receiving orthodontic treatment?
Has anyone in your family received orthodontic treatment?
How did they feel about the result?
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
Are you aware of clenching your teeth during the day?
Have you ever been told that you grind your teeth?
Do you have "tension" headaches?
Have you ever experienced chronic ringing in your ears?
Are you aware that some appointments will be during work hours?
Benefits
Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are intricate body parts and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Faulkner to perform a complete orthodontic evaluation.
Signature
Date

MonthDayYear
Date
Should be Empty:

Adult New Patient Form

Dental Insurance Information

Emergency Information

Medical History

For Female Patients Only

Dental History

Benefits