Adult Medical and Dental History

Adult Medical and Dental History
Patient Information
Patient Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Orthodontic Need and Referral
Why are you seeking orthodontic treatment?
Interested In

Other
How did you hear about us?
Primary Dental Insurance
Insurance Name
Insurance Phone
Please enter a valid phone number.Format: (000) 000-0000.
Subscriber Name

First NameMiddle NameLast Name
Subscriber ID
Subscriber Social Security
Subscriber Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Group Plan
Ortho Coverage
Authorization
Signature
Secondary Dental Insurance
Insurance Name
Insurance Phone
Please enter a valid phone number.Format: (000) 000-0000.
Subscriber Name

First NameMiddle NameLast Name
Subscriber ID
Subscriber Social Security
Subscriber Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Group Plan
Ortho Coverage
Authorization
Patient Signature
Dental Provider History
Dentist Name

First NameMiddle NameLast Name
Dentist Location - Street Address
Dentist Location - City
Dentist Location - State
Last Visit

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Last Visit
Have you ever had an orthodontic exam and evaluation?
Do you have, or have you had, any of the following? *
Physician and Medical History
Physician Name

First NameMiddle NameLast Name
Physician Location - Street Address
Physician Location - City
Physician Location - State
Are you currently taking any medications?
If yes, list medication and condition
List all allergies (medication/food/etc.)
Do you premedicate with antibiotics for dental procedures?
Medical History - Conditions

Other
If "Yes" to above questions, please specify
Do you have any medical problem not listed above?
I have read the above questions and understand them. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in the completion of the form. I will notify my orthodontist of any changes to my medical or dental health.
Patient Signature
Should be Empty:

Adult Medical and Dental History

Patient Information

Orthodontic Need and Referral

Primary Dental Insurance

Secondary Dental Insurance

Dental Provider History

Physician and Medical History