Adult Patient Information
Name
First Name
Middle Name
Last Name
Age
Sex
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
DOB
-
Month
-
Day
Year
Date
Number of years at current address
SS #
Employer
Occupation
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Years of employment
General Dentist
Last Visited
-
Month
-
Day
Year
Date
Confirm your appointments
Email
Text
Email for confirmation
example@example.com
Texting number for confirmation
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about our office?
Are there other family members who already see us? If so, who?
Spouse/Additional Contact Information
Name
First Name
Middle Name
Last Name
Relationship to Patient
DOB
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of years at current address
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Employer
Occupation
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Years of employment
Insuarance
Do you have orthodontic insurance?
Yes
No
PLEASE HAVE YOUR CARD AVAILABLE FOR FRONT DESK CLERK
Primary Insurance Company
Policy Holder's Name
First Name
Last Name
Member/Contract/Policy ID #
Group #
DOB
-
Month
-
Day
Year
Date
Policy Holder's SS #
Relationship to Patient
Medical History
Primary concern for orthodontic treatment
Medical Physician
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Last visit
-
Month
-
Day
Year
Date
Are you in overall good health?
List any medications now being taken, give reason
Has a doctor/dentist ever told you to pre-medicate with antibiotics before dental treatment?
Are you allergic to any of the following?
Aspirin
Latex
Nickel
Penicillin
Any other metals/plastics
Other
Dental History
Have your tonsils and/or adenoids been removed?
Yes
No
Have you had an orthodontist evaluation/treatment before?
Yes
No
Have you experienced jaw joint pain/discomfort?
Yes
No
Have you ever had an injury to teeth/mouth/chin?
Yes
No
Have you ever been informed of missing or extra permanent teeth?
Yes
No
Does anyone in your family have a similar dental condition?
Yes
No
Do/Have you ever had any of the following habits?
Lip biting/sucking
Clenching/grinding teeth
Mouth Breather
Nail Biting
Tongue thrusting
Thumb/finger sucking
Speech problems
Other
Responsible Party Signature
Date
-
Month
-
Day
Year
Date
Continue
Continue
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