Clone of Bailey-Welling Orthodontics

Adult New Patient Form
Complete your registration and health history from the comfort of home before your visit! Simply take a few moments to fill out our secure online form and hit "submit." Your details will be safely encrypted and sent directly to our office, so we’ll be ready for you when you come in 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 #
Format: (000) 000-0000.
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Marital Status
Sex
Email
example@example.com
Work Phone #
Format: (000) 000-0000.
Cell Phone #
Format: (000) 000-0000.
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?
Insured's Name
Insured's Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insurance Company
Group No.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber/Employee ID #
Insured's Employer
Do you have dual coverage?
Emergency Information
Name of nearest relative not living with you

First NameLast Name
Relationship
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
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 any concerns you may have:
Please list any medications that you are currently allergic to:
Have you ever been evaluated for or had orthodontic treatment before?
Have you had any injuries to your face, mouth, teeth or chin?
How do you feel about wearing orthodontic appliances?
Have your adenoids or tonsils been removed?
Have you been informed of any missing or extra permanent teeth?
Have you ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?
Do you brush your teeth daily?
Do you floss teeth daily?
Patient's Dentist
Date of Last Visit

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient's Physician
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you currently under the care of a physician?
Please describe your current physical health
Do you take or have you taken an osteoporosis medication?
Please list all the drugs you are currently taking:
Please list all allergies (drugs, foods, other):

Have you had any of the following medical problems?

Rows	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

Have you ever had any of the following medical problems?

Rows	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 you have had:

Do you have/had any of the following habits?

Rows	Yes	No
Chew/Smoke Tobacco
Clenching/Grinding Teeth
Mouth Breather
Nail Biting
Speech Problems

Signatures
Signature
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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