Welcome to the Orthodontist

Adult Patient Form
The benefits of a happy, healthy smile are immeasurable! A beautiful smile is a wonderful asset. Please fill out this form completely. The better we communicate, the better we can care for you.

1. About You

Name
Home Address

2. Spouse Information

Person Responsible for Account

3. Orthodontic Insurance

Primary

Orthodontic Coverage?
Dental Coverage?

Secondary

Orthodontic Coverage?
Dental Coverage?

In the event of an emergency, is there someone who lives near you that we should contact?

4. Medical History

Do you have a person physician?

Your current physical health is:
Are you currently under the care of a physician?
Are you taking any prescription/over-the-counter drugs?
For Women
Are you using a prescribed method of birth control?
Are you pregnant?
Are you nursing?
Have you ever had any of the following diseases or medical problems?
Abnormal Bleeding

Anemia

Artificial Bones/Joints/Valves

Asthma/Arthritis

Blood Transfusion

Cancer/Chemotherapy

Congenital Heart Defect

Diabetes

Difficulty Breathing

Drug/Alcohol Abuse

Emphysema

Epilepsy/Seizures/Fainting

Fever Blisters/Herpes

Glaucoma

Heart Attack/Stroke

Heart Murmur

Heart Surgery/Pacemaker

Hemophilia

Hepatitis

High/Low Blood Pressure

HIV+/AIDS

Hospitalized for Any Reason

Kidney Problems

Mitral Valve Prolapse

Psychiatric Problems

Radiation Treatment

Rheumatic/Scarlet Fever

Severe/Frequent Headaches

Shingles

Sickle Cell Disease/Traits

Sinus Problems

Tuberculosis (TB)

Ulcers/Colitis

Venereal Disease

Are you allergic to any of the following?
Aspirin

Any Metals/Platics

Codeine

Dental Anesthetics

Erythromycin

Latex

Penicillin

Tetracycline

Other

5. Dental History

Have you ever had or been evaluated for orthodontic treatment?
Have you ever had a serious/difficult problem associated with any previous dental work?
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?
Your current dental health is:
Do you like your smile?
Gums ever bleed?
Have you ever had an injury to your (check all that apply):
Do you generally breathe through your mouth?
If yes,

Do you have any missing or extra permanent teeth?
Have you ever taken Fosamax, or any other bisphosphonate?
Have you ever taken Phen-Fen?
Do you smoke or use tobacco in any form?

I understand that the information I have given today 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 my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

Thank you for filling out this form completely

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 the office, use the services of one or more credit reporting services.

If this office accepts insurance, I understand that I am responsible for payment services rendered and also responsible for pay any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office.

Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

Human Verification

Please enter the verification codes listed below to continue with submitting your form.