RJ Orthodontics - Adult Registration

New Adult Patient: Secure Registration Form

We would like to welcome you to our office. In an effort to provide the best service possible, we ask you to fill out this form as completely as possible. Thank You!
Patient Name

First NameLast Name
Social Security Number
Gender

MaleFemale
Birth Date

MonthDayYear
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Phone

Area CodePhone Number
Secondary Phone

Area CodePhone Number
Ok to leave message?

YesNo
E-mail
Employers Name
Occupation
Marital Status

SingleMarriedDivorcedWidowedSignificant Other
Spouse/Partner's Name

First NameLast Name
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Spouse/Partner Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Person(s) OK to release appointment or medically related information to concerning you
Relation To Patient
How did you hear about our practice?

AdInternetFamily/FriendPhysicianOther
Name of Person referring ( if applicable)

First NameLast Name
Insurance Information
Primary Dental Insurance Company
Phone Number

Area CodePhone Number
Group Number
Policy Number
Policy Holder's Name

First NameLast Name
Relation
Policy Holder's Social Security Number
Policy Holder's Date Of Birth

MonthDayYear
Employer
Work Phone Number

Area CodePhone Number
Co-Pay (if known)
Deductible (if known)
Health History
General Dentist
Last Visit
Have you visited an orthodontist before?

YesNo
If so when?

MonthDayYear
Reason
Have your tonsils or adenoids been removed?

YesNo
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?

YesNo
Do you have any missing or extra permanent teeth?

YesNo
Do your gums bleed?

YesNo
Do you smoke?

YesNo
Do you like your smile?

YesNo
Do you have speech problems?

YesNo
If so, explain
Have you ever had an injury to (select all that apply)

TeethMouthChin
Do you currently or have you ever had any of the following habits (check all that apply)

Clenching/Grinding TeethLip Sucking/BitingMouth BreathingNail BitingThumb/Finger SuckingChewing/Eating Problem
Are you currently being treated by a physician?

YesNo
Reason
Physician
Date of Last Visit

MonthDayYear
Phone Number

Area CodePhone Number
Do you have any allergies/sensitivities to medications or latex?

YesNo
If Yes, please list them
Are you currently taking any prescription or over the counter medications?

YesNo
If Yes, please list with dosage
Are you pregnant or nursing?

YesNoN/A
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.I understand that where appropriate, credit bureau reports may be obtained.
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Date

MonthDayYear
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Insurance Information

Health History