Adult New Patient Information

Patient Information

* Patient Name: (Required)

Gender: Male Female

Birth Date:

Age:

Home Address:

City:

State:

Zip:

Primary Phone Number:

Phone Type home cell

OK to leave message? Yes No

E-mail:

Employer's Name:

Occupation:

Spouse / Emergency Contact Information

Insurance Information

Primary Insurance

Primary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Secondary Insurance

Secondary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Dental History

General Dentist:

Last Visit:

What are the main concerns you would like orthodontics to correct?

Have you visited an orthodontist before? Yes No

If yes, when:

Reason:

Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)? Yes No

Do you have speech problems? Yes No

If so, explain:

Do your gums bleed? Yes No

Do you smoke? Yes No

Medical History

Are you currently being treated by a physician? Yes No

Reason:

Physician:

Last Visit:

Phone:

Do you have any allergies/sensitivities to medications or latex? Yes No

If yes, please list:

Are you currently taking any prescription or over-the-counter medications? Yes No

If yes, please list with the dosage:

Have you had any serious illnesses or operations? If yes, describe:

(Women) Are you pregnant? Yes No

Nursing? Yes No

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 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.

Submitted by:

Date: