New Patient Adult Form
Patient Information
Patient Name
*
First Name
Last Name
Preferred Name
Patient Gender
*
Male
Female
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Birthday
*
-
Month
-
Day
Year
Date
Patient Social Security Number
Patient Cell Phone Number
*
-
Area Code
Phone Number
Phone Carrier
*
Would You Like to Receive Text Messages?
*
Yes
No
Patient E-mail
*
Whom May We Thank for Referring You To Our Office?
*
Responsible Party Information
Responsible Party Name
First Name
Last Name
Responsible Party Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Responsible Party Birthday
-
Month
-
Day
Year
Date
Responsible Party Social Security Number
Responsible Party Cell Phone Number
-
Area Code
Phone Number
Responsible Party Phone Carrier
Would You Like To Receive Text Messages?
Yes
No
Responsible Party E-mail
Relationship to Patient
Dental Insurance
Does The Patient Have Dental Insurance (If yes, please complete the dental insurance fields)
*
Yes
No
Policy Holder's Name
First Name
Last Name
Policy Holder's Date of Birth
-
Month
-
Day
Year
Date
Policy Holder's Social Security Number
Insurance Company Name
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company Phone Number
-
Area Code
Phone Number
Policy Holder's ID Number
Group Number
Emergency Contact Information
Emergency Contact Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Relationship to Patient
*
Patient Medical History
Physician Name
*
First Name
Last Name
Physician Phone Number
*
-
Area Code
Phone Number
Date of Last Visit
*
-
Month
-
Day
Year
Date
Are you taking any medication?
*
Yes
No
Please list medications:
Are you allergic to any medication?
*
Yes
No
Please list allergies:
History of a major illness?
*
Yes
No
Please explain:
Have you had any operations?
*
Yes
No
Please explain:
Have you ever been in a serious accident?
*
Yes
No
Please explain:
Have you seen a physician in the last 12 months?
*
Yes
No
Please explain:
Are you pregnant?
*
Yes
No
Check any of the following that you have had or currently has:
Abnormal bleeding/Hemophilia
Anemia
Arthritis
Asthma/Hayfever
Bone Disorders
Congenital Heart Defect
Diabetes
Dizziness
Epilepsy
Gastrointestinal Disorders
Heart Problems
Heart Murmur
Hepatitis/Liver Problems
Herpes
High Blood Pressure
HIV/AIDS
Kidney Problems
Nervous Disorders
Pneumonia
Prolonged Bleeding
Radiation/Chemotherapy
Rheumatic Fever
Tuberculosis
Tumor or Cancer
Are there any other medical conditions we have not discussed that you feel we should be aware of?
Patient Dental History
Dentist Name
*
First Name
Last Name
Dentist Phone Number
*
-
Area Code
Phone Number
Date of Last Visit to Dentist
*
-
Month
-
Day
Year
Date
What concerns you most about your teeth?
Are you in any dental pain?
*
Yes
No
Have you ever experienced any unfavorable reaction to dentistry?
*
Yes
No
Have you ever lost or chipped any permanent teeth?
*
Yes
No
Have there been any injuries to your face, mouth or teeth?
*
Yes
No
Is any part of your mouth sensitive to temperature? Where?
*
Yes
No
Is any part of your mouth sensitive to pressure? Where?
*
Yes
No
Do your gums bleed when brushing?
*
Yes
No
Any type of thumb or tongue habit?
*
Yes
No
Are you a mouth breather?
*
Yes
No
Have you ever seen an orthodontist? If yes, who and when?
*
Yes
No
What is your attitude toward receiving orthodontic treatment
*
Favorable
Unfavorable
Has anyone in the family received orthodontic treatment?
*
Yes
No
How did they feel about the result?
Do your teeth or jaws ever feel uncomfortable first thing in the morning??
*
Yes
No
Experience jaw clicking or popping?
*
Yes
No
Experience "tension" headaches?
*
Yes
No
Have you ever experienced chronic ringing in the ears?
*
Yes
No
Do you need extra help with instructions?
*
Yes
No
Are you sensitive or self-conscious about your teeth?
*
Yes
No
I certify that I have read and understand the above information. To the best of my knowledge, the above questions have been answered accurately. I understand that providing false and incorrect information can be dangerous to my health.
Submit
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