New Patient Adult Form

New Patient Adult Form
Name

First NameLast Name
Preferred Name
Age
Sex
DOB

MonthDayYear
Date
Social Security #
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Email
example@example.com
Cell Phone
Please enter a valid phone number.
Employer
Employer Phone
Please enter a valid phone number.
Dentist Name
Last Visit

MonthDayYear
Date
Whom can we thank for referring you to our office?
Where did you see us?
Do you have orthodontic insurance?

YesNo
Primary Subscriber Name
DOB

MonthDayYear
Date
Subscriber's Social Security #
Employer
Name of Insurance
Insurance Phone
Please enter a valid phone number.
For Secondary Coverage Only:
Secondary Subscriber Name
DOB

MonthDayYear
Date
Subscriber's Social Security #
Employer
Name of Insurance
Insurance Phone
Please enter a valid phone number.
Please check the following as they apply:

Jaw Joint ProblemsHeart ProblemsKidney ProblemsLiver DiseaseHigh Blood PressurePregnancyCongenital Heart ConditionsHead or Facial InjuriesEar InfectionsAllergiesDiabetesBleeding DisorderAsthmaEpilepsySpeech ProblemsEndocrine DisorderNervous DisorderRheumatic FeverArtificial JointsOther
If Other, please describe:
Are you currently under the care of a physician?

YesNo
If Yes, please explain:
Dental History
Have you ever had any injuries to the face, mouth, or teeth?

YesNo
If Yes, please explain:
Have you had any TMJ (Jaw Joint) problems?

YesNo
If Yes, please explain:
Have you ever had Periodontal Disease?

YesNo
If Yes, please explain:
What part of your orthodontic problems concerns you the most?
Is there any additional information that you feel we need in order to make this a more enjoyable experience?
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Date

MonthDayYear
Date
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New Patient Adult Form

Dental History