Adult New Patient Information

Adult Registration Form - Ortho
* required field

Patient Information

Gender





Primary Phone Number
Secondary Phone Number



Spouse/Emergency Contact Information

Marital Status









Person Responsible for Account



Dental Insurance Information







Orthodontic Coverage






Orthodontic Coverage

Dental History


How did you hear about our practice?
Have you visited an orthodontist before?

Have your tonsils or adenoids been removed?
Have you been treated for bad bite, TMJ or Periodontal disease?
Do you have any missing or extra permanent teeth?
Have you ever had an injury to (select all that apply):
Do you have speech problems?
Are you frightened or anxious about Orthodontic treatment?
Are you concerned about the appearance of your teeth?
What aspect(s) of dental treatment are you most concerned with?
Reason for Consultation
Has there ever been any Orthodontic treatment for any other member of your family?





Medical History

Is your general health good at this time?
Are you currently being treated by a physician?

Do you have any allergies/sensitivities to medications or latex?
Are you currently taking any prescription or over-the-counter medications?
Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Have you had a blood transfusion?
Do you have any special problems not listed?
Have you ever been advised by your physician to take an antibiotic prior to any dental treatments?
Have you had any serious illnesses or operations?
Do you use tobacco (smoking or chewing)?

(Women)
Check if you have or have every had any of the following

Authorization

I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION. I grant authority to the Doctor and Staff to perform all procedures and treatments in my best interest. I authorize the Orthodontist to share treatment information with collaborating dentists and surgeons when appropriate. I authorize the Orthodontist to submit treatment information pertinent to this patient to the Insurance Company for billing purposes only. I understand that, when appropriate, Credit Bureau reports may be obtained.




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