Feldman Orthodontics - New Patient Form 😊✨

New Patient Form 😊✨

Please complete all necessary information across the five pages to help us serve you better.
Page 1 - Patient Information
Patient's Name

First NameLast Name
Age
Birthdate

MonthDayYear
Date
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Gender
Have you had previous orthodontic consultations?
Previous orthodontic treatment?
If so, when/where?
Doctor's Name
Primary reason for seeking this orthodontic evaluation
Who may we thank for referring you to Feldman Orthodontics?
Page 2 - Responsible Party Information
RESPONSIBLE PARTY INFORMATION (If patient is under 18)
Name
Relation to Patient
Marital Status
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Birthdate

MonthDayYear
Date
Employer
Years Employed?
Occupation
Spouse's Name (if applicable)
Spouse's Phone
Please enter a valid phone number.Format: (000) 000-0000.
Spouse's Employer
Spouse's Occupation
Page 3 - Dental Information
DENTAL INFORMATION
Patient's Dentist
Patient's Last Dental Visit
Has the patient had facial or dental injury due to accidents?
Has the patient ever experienced pain in his/her jaw joints?
Pain
Clicking
Popping
Earaches
Page 4 - Medical Information
MEDICAL INFORMATION
Patient's Overall Health
Is the patient currently under the care of a doctor, other than for routine examinations?
If yes, for what?
Is the patient currently taking any medication?
If yes, for what?
Does the patient currently have, or has the patient ever had any of the following? (if yes, check box)
Are you allergic to:
Please discuss any serious medical conditions the patient has/had
Page 5 - Insurance Information
INSURANCE INFORMATION
Policy Holder's Name
Insurance ID / Member ID
Birthdate

MonthDayYear
Date
Name of Insurance Co.
Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Address of Insurance Co.

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Policy #
Group #
Employer
Privacy Policy
Should be Empty:

New Patient Form 😊✨

Page 1 - Patient Information

Page 2 - Responsible Party Information

Page 3 - Dental Information

Page 4 - Medical Information

Page 5 - Insurance Information