Calles - San Rafael Orthodontics - Adult New Patient Form

Adult New Patient Form
Submit your health history form online to San Rafael Orthodontics

Save time before your appointment and fill out your 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 NameMiddle NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone #*
Birthdate*

MonthDayYear
Date
Sex*
E-mail*
example@example.com
Work Phone #*
Cell Phone #*
Employer Name*
Occupation*
Whom may we thank for referring you to our office?
Dental Insurance Information
Do you have dental insurance that covers orthodontic care?*

YesNo
Insured's Name
Insured's Birthdate

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

Street Address

Street Address Line 2

CityState / Province

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

YesNo
Emergency Information
Name of nearest relative not living with you*

First NameLast Name
Relationship*
Cell or Phone*
Please enter a valid phone number.
Complete Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What are the main concerns you would like orthodontics to address?
Please describe concerns:*
Please list any medications that you are currently allergic to:
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*
Date of Last Visit*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Patient's Physician*
Phone Number*
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/Metals
Allergy to Plastic
Any Hospital Stays
Any Operations
Asthma
Cancer
Congenital Heart Defect
Convulsions/Epilepsy

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

	Yes	No
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
Mouth Breather
Nail Biting
Speech Problems

Signatures
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in the patient's medical status. I authorize the dental staff to perform the necessary dental services I/my child may need.This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use services of one or more credit reporting agencies.If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.I understand that at the time of my office visit, my physical signature will be required to confirm the acknowledgements above.
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Please check your form to make sure it is complete and press the submit button when you are done. You will see a confirmation page when your form has been successfully submitted. Thank you!
Should be Empty:

Adult New Patient Form

Patient Information

Dental Insurance Information

Emergency Information

Signatures