Adult New Patient Information

About You
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Name

First NameLast Name
Gender
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
SS #
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
DL #
Email
example@example.com
Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you worked there?
Occupation
What time is the best to reach you?
Whom may we thank for referring you?
Other family members seen by us:
Dentist Name
Date of last dental cleaning:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Person Responsible for Account
Spouse Information
Name

First NameLast Name
Employer
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
SS #
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DL #
Relative/Friend Not Living With You

First NameLast Name
Relation
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Orthodontic Insurance

Primary
Do you have orthodontic coverage?
Do you have dental coverage?
Insurance Company
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone
Please enter a valid phone number.Format: (000) 000-0000.
Group # (Plan, Local, or Policy #)
Insured's Name

First NameLast Name
Relation to Patient
Insured's Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insured's ID #
Insured's Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Orthodontic Insurance

Secondary
Do you have orthodontic coverage?
Do you have dental coverage?
Insurance Company
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone
Please enter a valid phone number.Format: (000) 000-0000.
Group # (Plan, Local, or Policy #)
Insured's Name

First NameLast Name
Relation to Patient
Insured's Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insured's ID #
Insured's Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Payment is due in full at the time of treatment unless prior arrangements have been approved.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and for paying any co-payment that my insurance does not cover, including the deductible. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office. I understand that I am responsible for all costs of orthodontic treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

About You

Spouse Information

Orthodontic Insurance

Orthodontic Insurance