New Patient Form
Submit your health history form online to your orthodontist today. Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form and click "submit". Your information will be sent to our office with secure encryption. We will have your information when you arrive for your first appointment.
Patient Information
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Birthdate
*
/
Month
/
Day
Year
Date
Marital Status
*
Please Select
Single
Married
Divorced
Sex
*
Please Select
Male
Female
Email
example@example.com
If patient is a minor, parent's / guardian's name
If patient is a minor, name and ages of siblings
Whom may we thank for referring you to our office?
Sports/Hobbies/Musical Instruments
School/Occupation
Current Grade
Nickname
Person Responsible For Account
Same as Above
*
Yes
No
Relationship to Patient
*
Same as Above
*
Yes
No
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Social Security #
Employer
Occupation
No. of years employed
Is there an additional responsible party for this account?
*
Yes
No
Dental Insurance Information
Insured's Name
Insured's Birthdate
/
Month
/
Day
Year
Date
Social Security #
Insurance Company
Group No.
Phone
Insurance Co. Address
Insured's Employer
Subscriber/Employee ID #
Do you have dual coverage
*
Yes
No
Emergency Information
Name of nearest relative not living with you
*
Relationship
*
Cell or Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Complete Address
*
What are the main concerns that you would like orthodontics to address?
Please describe concerns
*
Has the patient ever been evaluated for or had orthodontic treatment before?
*
Yes
No
Have there been any injuries to the face, mouth, teeth or chin?
*
Yes
No
How does the patient feel about wearing orthodontic appliances?
Have adenoids or tonsils been removed?
*
Yes
No
Has the patient been informed of any missing or extra permanent teeth?
*
Yes
No
Has the patient ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?
*
Yes
No
Does the patient brush his/her teeth daily?
*
Yes
No
Floss his/her teeth daily?
*
Yes
No
Patient's Dentist
*
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Last Visit
Patient's Physician
*
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Is the patient currently under the care of a physician?
*
Yes
No
If patient is a minor, has puberty begun?
*
Yes
No
Please describe the patient's current physical health
*
Good
Fair
Poor
Do you take or have you taken an osteoporosis medication?
*
Yes
No
Please list all drugs that the patient is currently taking
Please list all allergies (drugs, foods, other)
What are the main concerns that you would like orthodontics to address?
Abnormal Bleeding
*
Yes
No
ADD/ADHD
*
Yes
No
Sleep Apnea
*
Yes
No
Allergy to Latex/Metals
*
Yes
No
Allergy to Plastic
*
Yes
No
Any Hospital Stays
*
Yes
No
Any Operations
*
Yes
No
Asthma
*
Yes
No
Cancer
*
Yes
No
Congenital Heart Defect
*
Yes
No
Convulsions/Epilepsy
*
Yes
No
Diabetes
*
Yes
No
Handicaps/Disabilities
*
Yes
No
Hearing Impairment
*
Yes
No
Heart Murmur
*
Yes
No
Hemophilia
*
Yes
No
Hepatitis
*
Yes
No
HIV+/AIDS
*
Yes
No
Kidney/Liver Problems
*
Yes
No
Psychological Counseling
*
Yes
No
Rheumatic/Scarlet Fever
*
Yes
No
Tuberculosis (TB)
*
Yes
No
Please discuss any medical problems that the patient has had
Does/Has the patient have/had any of the following habits?
Chew/Smoke Tobacco
*
Yes
No
Clenching/Grinding Teeth
*
Yes
No
Lip Sucking/Biting
*
Yes
No
Mouth Breather
*
Yes
No
Nail Biting
*
Yes
No
Nursing Bottle Habits
*
Yes
No
Speech Problems
*
Yes
No
Thumb/Finger Sucking
*
Yes
No
Tongue Thrust
*
Yes
No
Signatures
Signature
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
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!
Submit
Should be Empty: