Adult New Patient Information

Patient Name*
Gender
- Male
- Female
Social Security Number
Birth Date
MM slash DD slash YYYY
Age
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Phone Type
- Home
- Cell
OK to leave message?
- Yes
- No
Email
Spouse / Partner Information

Spouse/Partner's Name
Marital Status
- Single
- Married
- Divorced
- Widowed
- Significant Other
Social Security Number
Birth Date
MM slash DD slash YYYY
Driver's License Number
Address (if different than patient's)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Phone Type
- Home
- Cell
Emergency Contact Information

Emergency Contact's Name
Phone
Relation to Patient
Address (if different than child's)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Person(s) OK to release appointment or medically related information to
Relation to Patient
Insurance Information

Primary Insurance
Phone
Group Number
Policy Number
Member ID Number
Co-pay (if known)
Deductible (if known)
Policy Holder's Name
Relation to Patient
Policy Holder's SSN
Policy Holder's Date of Birth
MM slash DD slash YYYY
Employer
Phone
Secondary Insurance

Secondary Insurance Company
Phone
Group Number
Policy Number
Member ID Number
Co-pay (if known)
Deductible (if known)
Policy Holder's Name
Relation to Patient
Policy Holder's SSN
Policy Holder's Date of Birth
MM slash DD slash YYYY
Employer
Work Phone Number
Dental History

General Dentist Name
Date of Last Visit
How did you hear about our practice?
- Ad
- Internet
- Family/Friend
- Physician
- Other
Name of person referring (if applicable)
What are the main concerns you would like orthodontics to correct?
Have you visited an orthodontist before?
- Yes
- No
If yes, when?
Reason
Have we treated any other family members?
- Yes
- No
Name
Have you had your tonsils or adenoids been removed?
- Yes
- No
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
- Yes
- No
Do you have any missing or extra permanent teeth?
- Yes
- No
Has you ever had an injury to (select all that apply)
- Teeth
- Mouth
- Chin
Do you have speech problems?
- Yes
- No
If so, explain
Do your gums bleed?
Do you smoke?
Do you like your smile?
Do you currently or have you ever had any of the following habits (check all that apply)
- Clenching/Grinding Teeth
- Lip Sucking/Biting
- Mouth Breathing
- Nail Biting
- Thumb/Finger Sucking
- Chewing/Eating Problem
Medical History
- Yes
- No
Are you currently being treated by a physician?
Reason
Physician
Date of last visit
MM slash DD slash YYYY
Phone Number
Do you have any allergies/sensitivities to medications or latex?
- Yes
- No
If yes, please explain
Are you currently taking any prescription or over-the-counter medications?
- Yes
- No
If yes, please list with the dosage
Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
- Yes
- No
Have you had any serious illnesses or operations? If yes, describe
Have you ever had a blood transfusion?
- Yes
- No
If yes, give approximate dates.
(Women) Are you pregnant?
- Yes
- No
Nursing?
- Yes
- No
Taking birth control pills?
- Yes
- No
Check if your child has or has ever had any of the following
- Anemia
- Arthritis, Rheumatism
- Artificial Heart Valves
- Artificial Joints
- Asthma
- Back Problems
- Blood Disease
- Cancer
- Chemical Dependency
- Chemotherapy
- Circulatory Problems
- Cortisone Treatments
- Cough, Persistent
- Coughing Blood
- Diabetes
- Epilepsy
- Fainting
- Glaucoma
- Headaches
- Heart Murmur
- Heart Problems
- Hemophilia
- Hepatitis
- High Blood Pressure
- HIV/AIDS
- Jaw Pain
- Kidney Disease
- Liver Disease
- Mitral Valve Prolapse
- Pacemaker
- Radiation Treatment
- Respiratory Disease
- Rheumatic Fever
- Scarlet Fever
- Shortness of Breath
- Skin Rash
- Stroke
- Swelling of Feet or Ankles
- Thyroid Problems
- Tobacco Habit
- Tonsilitis
- Tuberculosis
- Ulcer
- Venereal Disease (STD)
Authorization: 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 child's medical status. I hereby authorize the release of any information pertaining to my child's 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.

Submitted by
Date
MM slash DD slash YYYY
Email
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