New Patient Form

New Patient Form
Patient Information
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Birthdate

MonthDayYear
Date
Marital Status
Sex
Email
example@example.com
Parent/guardian's name (if patient is a minor)
Name/ages of siblings (if patient is a minor)
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 NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

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

MonthDayYear
Date
Have you been at this address longer than 3 years?*

YesNo
Previous Address

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
Number of years employed
Is there an additional responsible party for this account?*

YesNo
Relationship to Patient
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Marital Status
Have you been at this address longer than 3 years?*

YesNo
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental Insurance Information
Insured's Name

First NameMiddle NameLast Name
Insured's Birthday

MonthDayYear
Date
Social Security #
Insurance Company
Group No.
Phone
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 NameMiddle NameLast Name
Insured's Birthday

MonthDayYear
Date
Social Security #
Insurance Company
Group No.
Phone
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*

First NameLast Name
Type a question*
Phone Number*
Please enter a valid phone number.
Complete 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*
Phone Number
Please enter a valid phone number.
Date of Last Visit

MonthDayYear
Date
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?
Abnormal Bleeding*

YesNo
ADD/ADHD*

YesNo
Sleep Apnea*

YesNo
Allergy to Latex/Metals*

YesNo
Allergy to Plastic*

YesNo
Any Hospital Stays*

YesNo
Any Operations*

YesNo
Asthma*

YesNo
Cancer*

YesNo
Congenital Heart Defect*

YesNo
Convulsions/Epilepsy*

YesNo
Diabetes*

YesNo
Handicaps/Disabilities*

YesNo
Hearing Impairment*

YesNo
Heart Murmur*

YesNo
Hemophilia*

YesNo
Hepatitis*

YesNo
HIV+/AIDS*

YesNo
Kidney/Liver Problems*

YesNo
Psychological Counseling*

YesNo
Rheumatic/Scarlet Fever*

YesNo
Tuberculosis (TB)*

YesNo
Please discuss any medical problems that the patient has had
Does/Has the patient have/had any of the following habits?
Chew/Smoke Tobacco*

YesNo
Clenching/Grinding Teeth*

YesNo
Lip Sucking/Biting*

YesNo
Mouth Breather*

YesNo
Nail Biting*

YesNo
Nursing Bottle Habits*

YesNo
Speech Problems*

YesNo
Thumb/Finger Sucking*

YesNo
Tongue Thrust*

YesNo
Notice of Privacy Practices

**You May Refuse to Agree to This Acknowledgement**
Please download a copy of our Notice of Privacy Practices PDF
Acknowledgment of Receipt
Patient Name, or Parent / Guardian of Patient:*
Please check the following numbers that we way leave messages at:

Home PhoneWork PhoneCell Phone
Cell Phone Provider (Required to receive text reminders):
Please enter a valid phone number.
May we send you information via mail and e-mail (including reminder postcards)?*

YesNo
Email Address:
example@example.com
Our office utilizes an automated reminder system for appointments. Please indicate your preferred contact method. You may indicate more than one.*

Text MessageEmail
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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?

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

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

Notice of Privacy Practices

Acknowledgment of Receipt

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