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.
