New Patient Packet

New Patient Information Packet
Patient Information

Please complete all of the information requested.
Date

MonthDayYear
Date
Nickname
Patient Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
D.O.B.

MonthDayYear
Date
Sex
Email
example@example.com
Family Dentist
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dentist Phone
Please enter a valid phone number.
Last Visit

MonthDayYear
Date
School
Whom may we thank for referring you to our office?
Is there another family member we have treated?
Responsible Party Information
Name

First NameLast Name
Marital Status
Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different than above)

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.
Work Phone
Please enter a valid phone number.
Email
example@example.com
Social Security Number
D.O.B.

MonthDayYear
Date
Relationship to Patient
Employer
Occupation
Number of Years Employed
Parent or Spouse's Name

First NameLast Name
Relationship to Patient
Employer
Occupation
Number of Years Employed
Social Security Number
D.O.B.

MonthDayYear
Date
Work Phone
Please enter a valid phone number.
Insurance Information
Do you have Orthodontic Insurance?

YesNo
Is there more than one coverage?

YesNo
Insured's Name

First NameLast Name
Insured's Social Security Number
Insurance Company
Group #
Employee ID
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone
Please enter a valid phone number.
Insured's Name

First NameLast Name
Insured's Social Security Number
Insurance Company
Group #
Employee ID
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone
Please enter a valid phone number.
Medical History
Is the patient in good health?

YesNo
Any history of major illness or health problems?

YesNo

Has the patient been treated for any of the following conditions?*

	Yes	No
Hepatitis
AIDS
Diabetes
Rheumatic Fever
Asthma
Kidney Problems
Prolonged Bleeding
Tuberculosis

Does the patient need antibiotic premedication for any dental procedures?

YesNo
Have the tonsils and adenoids been removed?

YesNo
BothTonsils OnlyAdenoids Only
At what age?
Has the patient ever had an ear/nose and throat specialist examination?

YesNo
List any drugs or medications now being taken and for what purpose(s):
List any allergies or drug sensitivities:
Name of Personal Physician
The next three questions are for children and adolescent patients only.
For growth assessment reasons, has the patient reached puberty?

YesNo
Your estimate of the rate of growth in the last 6 months?

SlowMediumFast
Please provide the Height of:
Patient Height
Mother Height
Father Height
In your own words, why are you seeking orthodontic care (what do you think is the problem)?
Dental History
Has the patient seen an orthodontist previously (for treatment or second opinion)?

YesNo
Was any orthodontic treatment rendered?

YesNo
Any baby or permanent teeth removed by dentist?

YesNo
Has the patient been informed of any missing or extra permanent teeth?

YesNo
Have there been any injuries to the face, mouth, or teeth?

YesNo
Any difficulty in breathing through the nose (awake or asleep)? (Mouth-breathing)

YesNo
Any speech problems?

YesNo
Any habits such as thumb sucking, lip biting, nail biting?

YesNo
Please specify:
At what age did the habit stop?
Does the patient have any clicking or discomfort in the jaw joints (near the ears)?

YesNo
Does the patient clench or grind the teeth?

YesNo
Name of Emergency Contact
Emergency Contact Phone
Please enter a valid phone number.
Signature of Custodial Parent or Guardian

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Date

MonthDayYear
Date

Acknowledgment of Receipt of Notice of Privacy Practices
I have received a copy of the Notice of Privacy Practices for the above-named practice.
Name of Patient

First NameLast Name
Signature of Patient or Custodial Parent/Guardian

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Date

MonthDayYear
Date

New Patient Information Packet

Patient Information

Responsible Party Information

Insurance Information

Medical History

Dental History

Acknowledgment of Receipt of Notice of Privacy Practices

Authorization for the Release of Information