Clone of Child Patient Information Form

Adult Patient Information Form
Speed up your visit by completing your registration and health history forms online ahead of time! Just spend a few moments filling out this private form and select "submit". Your details will be securely encrypted and sent directly to our office. Everything will be ready for us to review when you arrive for your first appointment.
Name

First NameMiddle NameLast Name
I prefer to be called (Nickname):
Birthdate

MonthDayYear
Date
Sex
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type
Marital Status
Email
example@example.com
Have we seen any other family members?
Please enter names of other family members seen by us:
Whom may we thank for referring you to our office?
Primary Dental Insurance Information
Do you currently have dental insurance? If so, may we verify your benefits?
Policy Holder's Name

First NameLast Name
Policy Holder's Birthdate

MonthDayYear
Date
Policy Holder's SSN
We may need this to verify your policy
Policy Holder's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Policy Holder's Relationship to Patient
Insurance Card Image Upload

If you would prefer to send us images of your insurance card, please take clear photos of the front and back of the card, and upload here. Otherwise, please proceed to the next section to fill in your insurance information
Cancelof
Insurance Company Name
Insurance Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Member ID
Group # (Plan, Local, or Policy #)
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have secondary insurance?
Secondary Dental Insurance Information
Policy Holder's Name

First NameLast Name
Policy Holder's Birthdate

MonthDayYear
Date
Policy Holder's SSN
We may need this to verify your policy
Policy Holder's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Policy Holder's Relationship to Patient
Insurance Card Image Upload

If you would prefer to send us images of your insurance card, please take clear photos of the front and back of the card, and upload here. Otherwise, please proceed to the next section to fill in your insurance information
Cancelof
Insurance Company Name
Insurance Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Member ID
Group # (Plan, Local, or Policy #)
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental History
What are the main concerns you or your dentist would like orthodontics to address?
General Dentist
Date of Last Visit
Have you ever seen an orthodontist?
If yes, who?
When?
Have there been any injuries to the face, teeth, jaw, mouth, or chin? If yes, please explain:
Enter "n/a" if this does not apply to you
Have you ever had pain/tenderness in your jaw joint? (TMJ/TMD)?
Are you aware of any missing or extra permanent teeth?
Do you brush your teeth daily?
Do you floss your teeth daily?

Do you have a history of any of the following habits?

Rows	Yes	No
Clenching/Grinding Teeth
Lip Biting/Sucking
Mouth Breather
Nail Biting
Tongue Thrust
Chew/Smoke Tobacco

Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect treatment you receive from our office. This information is kept strictly confidential.
Physician
Date of Last Visit
Are you currently under the care of a physician for any specific conditions?
If yes, please explain:
Please list any medications that you are currently taking and for what conditions:
Enter "n/a" if you are not taking any medications
Do you take or have you ever taken bisphosphonates or other medications to treat bone disorders or osteoporosis?
Please list any allergies you currently have:
Enter "n/a" if you do not have any allergies
Are you currently pregnant?

Have you ever had any of the following medical problems?

Rows	Yes	No
Abnormal Bleeding
Allergies to any drugs
Allergy to latex
Allergy to metals or plastics
Any Hospital Stays
Any Operations
Asthma
Arthritis
Bone Disorders
Cancer
Congenital Heart Defect
Diabetes
Epilepsy/Convulsions
Handicaps/Disabilities
Hearing Impairment

Rows	Yes	No
Heart Murmur/Heart Problems
Hemophilia
Hepatitis
HIV+/AIDS
High Blood Pressure
Gastrointestinal Disorders
Genetic Disorders
Kidney/Liver Problems
Neurological Disorders
Neurodivergence/Autism
Psychological/Psychiatric Treatment
Radiation/Chemotherapy
Rheumatic Fever
Tuberculosis (TB)
Joint Replacement

Are there any medical conditions that we have not asked about that you feel we should be aware of?
Emergency Contact

Please list an emergency contact not living with you
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Person that Completed this Form

First NameLast Name
Relationship to Patient
Today's Date

MonthDayYear
Date
For Office Use Only
Form Reviewed By/Date
Should be Empty:

Adult Patient Information Form

Primary Dental Insurance Information

Secondary Dental Insurance Information

Dental History

Medical History

Emergency Contact