• Adult Patient Information Form

    Adult Patient Information Form

  • Sex*
  • Birth Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Marital Status*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date Of Last Visit*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Date Of Last Visit*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Spouse's Information

  • Birthday
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Contact Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Person Responsible Account

  • Who Is Responsible For This Account?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Orthodontic Insurance

  • Do you have orthodontic insurance?*
  • Format: (000) 000-0000.
  • Policy Owner's Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year

  • Medical History

  • Do you currently feel healthy?*
  • Have you ever been evaluated or had orthodontic treatment before?*
  • Have you been informed of any missing or extra permanent teeth?*
  • Have you experienced problems with previous dental work?*
  • Have you ever had any pain / tenderness in your jaw joint (TMJ/TMD)?*
  • Has your jaw ever clicked, popped or locked?*
  • Have you noticed your teeth shifting or a change in your bite?*
  • Do you have frequent headaches?*
  • Do you still have your wisdom teeth?*
  • Have there been any injuries to your face, mouth, teeth or chin?*
  • Do you need to be premedicated before dental work?*
  • Have adenoids or tonsils been removed?*
  • Do you brush your teeth daily?*
  • Do you floss your teeth daily?*
  • Do your gums bleed?*
  • Are you taking fluoride supplements?*
  • Females: Do you take birth control pills?
  • Females: Are you pregnant?
  • Are you Allergic to any of the following?*
  • Do you now have or have you had any of the following habits?*
  • Do you now have or have you had any of the following?*

  • Signature

  • Our office is committed to meeting or exceeding the standards of infection control
    mandated by OSHA, the CDC and the ADA.

    We reserve the right to verify the credit status prior to extending credit for treatment.

    I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in the medical status of the patient named herein. Additionally, I hereby consent to an initial examination of the patient named herein.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: