New Patient Form
Date
Patient's First Name
Patient's Last Name
Nickname
Birthday
Age
Sex
Address
City
State
Zipcode
School Attending
Home Phone
Work Phone
Brothers & Sisters/Names & Ages
Who May We Thank For Referring You To Our Office?
Are You Transferring From Another Orthodontist?
Yes
No
Transferring Orthodontist Name
Office Phone Number
Date of Last Visit
Responsible Party
Name
Social Security Number
Birth Date
Relationship to Patient
Address
City
State
Zipcode
Home Phone
Work Phone
Cell Phone
Email Address
Correspondences should be sent to
Employer
Occupation
How long employer?
Spouse
Spouse Name
Social Security Number
Birth Date
Relationship to Patient
Employer
Occupation
How long employer?
Emergency Contact
Health History
Name of General Dentist
Date of Last Visit
Have you had any severe head or face injuries?
Yes
No
Have you had a history of thumb or finger sucking?
Yes
No
Did you stop? When?
Do you play any musical (wind) instruments?
Yes
No
What instrument?
Have you consulted an orthodontist previously?
Yes
No
Have you had any previous orthodontic treatment?
Yes
No
Does any genetically related family member have a similar facial/dental appearance?
Please Check All That Apply
Yes
No
Apprenhensive about dental care
Yes
No
Discomfort from teeth
Yes
No
Teeth are shifting
Yes
No
Frequent canker sores
Yes
No
Fluoride Treatments
Yes
No
Speech Therapy
Yes
No
Injury Involving teeth
Yes
No
Frequent clenching of teeth
Yes
No
Grinding of teeth
Yes
No
Wake up with sore teeth
Yes
No
Wake up with sore jaw
Yes
No
Jaw joint sounds
Yes
No
Jaw joint pain
Yes
No
Jaw 'tires' when eating
Yes
No
jaw catches when opening
Yes
No
Jaw locks in closed position
Yes
No
Jaw locks in open position
Yes
No
Facial pain
Yes
No
Frequent headaches
Yes
No
Neck or shoulder pain
Yes
No
Tonsils/adenoids removed
Yes
No
Missing permanent teeth
Yes
No
Discomfort from gums
Yes
No
Require premedication for dental procedures
If you have checked yes to any of the above, please explain:
Are you in good health?
Yes
No
If you answered no, please explain
Are you currently under a physician's care?
Yes
No
Name of physician
Please list the medications that you are taking
Please list allergies
Please list drug sensitivity
Have you ever been told you need to premedicate for dental procedures?
Yes
No
Please explain:
FOR OUR FEMALE PATIENTS-Are you pregnant?
Yes
No
Please Check All That Apply
Yes
No
AIDS antibody positive
Yes
No
Allergic to latex
Yes
No
Allergic to metals
Yes
No
Anemia
Yes
No
Arthritis
Yes
No
Asthma
Yes
No
Blood Disease
Yes
No
Bone Disease
Yes
No
Congenital heart defect
Yes
No
Cancer
Yes
No
A family member with a history of cancer
Yes
No
Frequent Colds or Flu
Yes
No
Diabetes
Yes
No
Ever been hospitalized
Yes
No
Emotional problems
Yes
No
Endocrine problems
Yes
No
Epilepsy
Yes
No
Hearing problems
Yes
No
Heart attack/Stroke
Yes
No
Heart Murmur
Yes
No
Hepatitis
Yes
No
Herpes
Yes
No
Hormone therapy
Yes
No
Jaundice
Yes
No
Kidney disease
Yes
No
Mouth breathing
Yes
No
Prolonged bleeding
Yes
No
Psychological counseling
Yes
No
Rheumatic fever
Yes
No
Seizures
Yes
No
Tonsillitis/adenitis
Yes
No
Tuberculosis
If you checked yes to any of the above, please explain...
Is there any other information that may be helpful?
Why are you seeking an orthodontic consultation?
What's Most Important to You?
We consider your satisfaction to be of utmost importance, and this starts by personalizing your orthodontic experience. Please review the treatment aspects below that our skilled team of professionals can deliver using several state-of-the-art technologies.
(Please rank your top three treatment aspects from 1 to 3)
Esthetics: I would prefer it if people don’t notice I’m in orthodontic treatment.
3
2
1
Colors: I want to have fun displaying different colors (i.e. on holidays, for sports teams, etc).
3
2
1
Comfort: I want the highest degree of comfort possible during treatment.
3
2
1
Length of Time in Orthodontic Treatment: I want to have a beautiful smile as quickly as possible.
3
2
1
Visit Frequency: I want to come to the orthodontist as few times as possible.
3
2
1
Appointment Length: I want to sit in the chair for short periods during adjustments appointments.
3
2
1
Schedule: I'd like appointments to accommodate my own schedule (before or after school/work).
3
2
1
Punctuality: I want to be seen on time for adjustment appointment.
3
2
1
Treatment Cost: The down payment and monthly payment are major considerations.
3
2
1
Other
3
2
1
If Other, please explain
Orthodontic Insurance Information
Do you have orthodontic dental insurance?
Yes
No
Patient's relationship to insured:
Self
Child
Spouse
Other
Insured Name
Insured Birth Date
Insured Social Security # or ID #
Employer (Company Name)
Office Phone
Address
Dental Insurance Company
Group Number
Address
Office Phone
Is the patient over 18 years of age?
Yes
No
Full or part-time student?
Full
Part-time
If yes, what school attending?
By signing below I understand that the information I have given is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes.
In the separation/divorce situations, the individual who initiates services with us is held financially responsible. We do not bill another person or an estranged spouse unless that individual informs us in writing of his or her willingness to pay for services. We will assist you in filing your insurance. Services rendered are charged to the patient, not the insurance company, and patients are expected to take care of their fees as services are rendered unless special arrangements have been made.
Signature
Date
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