Teeters Orthodontics - New Patient Form

New Patient Form

Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form and click "submit". Your information will be sent to our office with secure encryption. We will have your information when you arrive for your first appointment.
Patient Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Home Phone*
Please enter a valid phone number.
Birthdate*

MonthDayYear
Date
Marital Status*
If patient is a minor, parent's / guardian's name
If patient is a minor, name and ages of siblings
Whom may we thank for referring you to our office?*
Sports/Hobbies/Musical Instruments
School/Occupation
Current Grade
Nickname
Person Responsible For Account
Same as Above?*

YesNo
Relationship to Patient
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Home Phone
Please enter a valid phone number.
Marital Status
Birthdate

MonthDayYear
Date
Previous Address (if at current address less than 3 years)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Social Security #
Employer
Occupation
No. of years employed
Is there an additional responsible party for this account?

YesNo
Relationship to Patient
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Home Phone
Please enter a valid phone number.
Marital Status
Birthdate

MonthDayYear
Date
Previous Address (if at current address less than 3 years)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Social Security #
Employer
Occupation
No. of years employed
Dental Insurance Information
Insured's Name

First NameLast Name
Insured's Birthdate

MonthDayYear
Date
Social Security #
Insurance Company
Group No.
Phone Number
Please enter a valid phone number.
Insurance Co. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured's Employer
Subscriber/Employee ID #
Do you have dual coverage?*

YesNo
Insured's Name

First NameLast Name
Insured's Birthdate

MonthDayYear
Date
Social Security #
Insurance Company
Group No.
Phone Number
Please enter a valid phone number.
Insurance Co. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured's Employer
Subscriber/Employee ID #
Emergency Information
Name of nearest relative not living with you**
Relationship*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What are the main concerns that you would like orthodontics to address?
Please describe concerns*
Has the patient ever been evaluated for or had orthodontic treatment before?*

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

YesNo
How does the patient feel about wearing orthodontic appliances?*
Have adenoids or tonsils been removed?*

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

YesNo
Has the patient ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?*

YesNo
Does the patient brush his/her teeth daily?*

YesNo
Floss his/her teeth daily?*

YesNo
Patient's Dentist*
Dentist's Phone
Please enter a valid phone number.
Date of Last Visit

MonthDayYear
Date
Patient's Physician*
Physician's Phone
Please enter a valid phone number.
Is the patient currently under the care of a physician?*

YesNo
If patient is a minor, has puberty begun?*

YesNo
Please describe the patient's current physical health*

GoodFairPoor
Do you take or have you taken an osteoporosis medication?*

YesNo
Please list all drugs that the patient is currently taking
Please list all allergies (drugs, foods, other)

Has the patient ever had any of the following medical problems?*

	Yes	No
Abnormal Bleeding
ADD/ADHD
Sleep Apnea
Allergy to Latex
Allergy to Metals
Allergy to Plastic
Any Hospital Stays
Any Operations
Asthma
Cancer
Congenital Heart Defect
Convulsions/Epilepsy
Diabetes
Handicaps/Disabilities
Hearing Impairment
Heart Murmur
Hemophilia
Hepatitis
HIV+/AIDS
Kidney/Liver Problems
Psychological Counseling
Rheumatic/Scarlet Fever
Tuberculosis (TB)

Please discuss any medical problems that the patient has had

Does/Has the patient have/had any of the following habits?*

	Yes	No
Chew/Smoke Tobacco
Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breather
Nail Biting
Nursing Bottle Habits
Speech Problems
Thumb/Finger Sucking
Tongue Thrust

Acknowledgement and Consent
BENEFITS AND INFORMED CONSENT

Benefits of Orthodontics: Improved esthetics, health, and function. Orthodontics is a service that generally 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 an intricate body part and a dynamic physiologic system that is influenced by both genetics and the environment. Therefore, some teeth may fail to respond to treatment and an ideal result may not be attainable. If good oral hygiene is not practiced, tooth decay and periodontal disease can result, which may manifest as permanent white spots, cavities, or tooth mobility/loss in rare cases. 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, including but not limited to professional publications, social media, and consultations with other professionals.
3-D CONE BEAM SCANS

Affiliated Orthodontics now offers an exciting new technology for our patients and for patients of other doctors who might be referred to our office. This technology is known as Cone Beam Computer Tomography (CBCT) Imaging, sometimes referred to as 3-D radiographs or X-rays. Using a CBCT gives us the ability to take 3-D images of the teeth, jaws, bones, and facial structures with much less energy than a typical CT scan used in hospitals. 3-D imaging provides us the opportunity for improve diagnostics for our patients, especially in cases of crowded teeth, impacted teeth, missing teeth, dental implant planning, surgical treatment, oral pathology, as well as complex cases. As a courtesy to our patients, we will submit to insurance for this service, but you will not be charged regardless if your insurance covers it or not.

Understandably, you may have questions about exposure to these types of x-rays. Here are some facts you should know about 3-D Imaging. A CBCT in 10 seconds is equivalent to:
- About ¼ as much radiation as a full series of digital dental x-rays
- About 1/5 as much radiation as a full series of standard dental x-rays
- About 1/10 as much radiation as a full mammogram series
- About 1/25 as much radiation as a head medical CT scan
CBCT Imaging, therefore, offers our patients enhanced diagnostic value at significantly reduced exposure. At the same time, CBCT scans can capture an image of the entire head and most of the neck. As dentists and orthodontists, we are trained to evaluate the teeth, the jaws, and the surrounding periodontal bone. Our training does not provide for evaluating and diagnosing outside of those areas. However, since CBCT imaging can cover a broader area, we want to offer you the opportunity to have your CBCT scan read by an oral radiologist, who is trained and licensed to evaluate a broader area. CBCT scans may show evidence of disease of the cervical spine, skull, arteries, and more. We can refer you to a radiology group for this purpose. The cost is $150.00 to have my CBCT read by an oral radiologist.
If you are interested in taking advantage of this services, please initial the applicable section and sign the acknowledgement below.

I would like to have a CBCT radiograph taken and evaluated by my Orthodontist for improved diagnostics, but would NOT like to have it sent to an oral radiologist. I understand the risks and benefits of having my CBCT read and interpreted by an oral radiologist, however I knowingly decline such a referral.I would like to have a CBCT radiograph taken and evaluated by my Orthodontist for improved diagnostics, and would like to have it read and interpreted by an oral radiologist. I understand I am responsible for the additional cost of $150.00.
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New Patient Form

Patient Information

Person Responsible For Account

Dental Insurance Information

Emergency Information

What are the main concerns that you would like orthodontics to address?

Acknowledgement and Consent

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