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Durham & Oxford, NC's Favorite Orthodontist For Braces
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Orthodontics
New Patients
FAQ
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Emergency Care
Early Treatment
Adolescent Treatment
Adult Braces
Existing Patients
Why Wilson?
Get Your Braces Off 35% Faster
Most Insurances Accepted
100% Satisfaction Guarantee
Experience
Virtually No Wait Times
3D Imaging
The Most Advanced Technology
Many Treatment Options
VIP Smile Club
Same Day Appointments & Same Day Starts Available
Family Discounts Available
Award Winning & 5-Star Rated
Reviews
Blog
Contact Us
Our Durham, NC
Orthodontics Office
Our Oxford, NC
Orthodontics Office
New Patient Form
New Patient Form
Patient Information
First Name
Last Name
Middle Name
Street Address
City
State
Zip
Home Phone
Birthdate
Marital Status
Sex
If patient is a minor, parent's / guardian's name
Name and Ages of Siblings
Email Address
Whom may we thank for referring you to our office?
Sports/Hobbies/Musical Instruments
School/Occupation
Current Grade
Nickname
Person Responsible For Account
First Name
Last Name
Middle Name
Street Address
City
State
Zip
Have you been at this address longer than 3 years? Yes Previous Street Address
City
State
Zip
Relationship to Patient
Social Security #
Birthdate
Home Phone
Work Phone
Cell Phone
Email Address
Employer
Occupation
No. of years employed
Spouse's Name
Sex
Relationship to Patient
Social Security #
Birthdate
Work Phone
Cell Phone
Spouse's Employer
Occupation
No. of years employed
Dental Insurance Information
Insured's Name
Insured's Employer
Insured's Birthdate
Social Security #
Insurance Company
Group No.
Phone Number
Subscriber/Employee ID #
Insurance Co. Address
Do you have dual coverage?
No
If Yes
Insured's Name
Insured's Employer
Insured's Birthdate
Social Security #
Insurance Company
Group No.
Phone Number
Subscriber/Employee ID #
Insurance Co. Address
Emergency Information
Name of nearest relative not living with you
Relationship
Cell or Phone
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?
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 Number
Date of Last Visit
Patient's Physician
Phone Number
Is the patient currently under the care of a physician?
Yes
No
Has puberty begun?
Yes
No
If yes, when?
Please describe the patient's current physical health:
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)
Has the patient ever had any of the following medical problems?
Abnormal Bleeding
Allergy to Plastic
Asthma
Convulsions/Epilepsy
Hearing Impairment
Hepatitis
Psychological Counseling
ADD/ADHD
Any Hospital Stays
Cancer
Diabetes
Heart Murmur
HIV+/AIDS
Rheumatic/Scarlet Fever
Allergy to Latex/Metals
Any Operations
Congenital Heart Defect
Handicaps/Disabilities
Hemophilia
Kidney/Liver Problems
Tuberculosis (TB)
Please discuss any medical problems that the patient has had
Does/Has the patient have/had any of the following habits?
Chew/Smoke Tobacco
Mouth Breather
Speech Problems
Clenching/Grinding Teeth
Nail Biting
Thumb/Finger Sucking
Lip Sucking/Biting
Nursing Bottle Habits
Tongue Thrust
Signatures
*
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in the patient's medical status. I authorize the dental staff to perform the necessary dental services I/my child may need.
Signature2
*
This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use services of one or more credit reporting agencies.
Signature3
*
If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.
Signature4
*
I understand that at the time of my office visit, my physical signature will be required to confirm the acknowledgements above.
Your 5-Star Rated & Favorite Orthodontist in Durham & Oxford, NC
"Dr. Wilson turned a crooked smile into a fabulous smile, and in only 13 months!!"
- Alise M.
Mother of SureSmile
Braces Patient
"Amazing service and staff! Excellent experience!"
- T. Elliott
"Dr. Wilson and his staff are great. I would highly recommend them to anyone who is looking into getting braces."
- Gergely
"Thank you Dr. Wilson and staff for kick starting my transformation..."
- Jo M., Oxford, NC
Read More
Leave Us A Review
MENU
Home
About
Orthodontics
New Patients
FAQ
Your Treatment Options
Emergency Care
Early Treatment
Adolescent Treatment
Adult Braces
Existing Patients
Why Wilson?
Get Your Braces Off 35% Faster
Most Insurances Accepted
100% Satisfaction Guarantee
Experience
Virtually No Wait Times
3D Imaging
The Most Advanced Technology
Many Treatment Options
VIP Smile Club
Same Day Appointments & Same Day Starts Available
Family Discounts Available
Award Winning & 5-Star Rated
Reviews
Blog
Contact Us
Our Durham, NC
Orthodontics Office
Our Oxford, NC
Orthodontics Office
