Ortho Adult

We would like to welcome you to our office. In an effort to provide the best service possible, we ask you to fill out this form as completely as possible.

Thank You!

Patient Information

Patient Name:

Male Female

Social Security Number: Birth Date: Driver License:
Home Address: City: State: Zip:

Primary Phone: home cell Ok to leave message? Yes No

Secondary Phone: home cell other Ok to leave message? Yes No

E-mail: Employer's Name: Occupation:

Spouse / Partner Information

Marital Status Single Married Divorced Widowed Significant Other

Spouse/Partner's Name:
Emergency Contact Name: Phone Number: Relation: Address: City: State: Zip:

Person(s) OK to release appointment or medically related information to concerning you: Relation(s):

Insurance Information

Primary Insurance Company: Phone Number: Group Number: Policy Number: Member ID Number: Policy Holder's Name: Relation: Policy Holder's Social Security Number: Policy Holder's Date of Birth:
Employer: Work Phone Number: Co-pay (if known): Deductible (if known):

Secondary Insurance Company: Phone Number: Group Number: Policy Number: Member ID Number: Policy Holder's Name: Relation: Policy Holder's Social Security Number: Policy Holder's Date of Birth:
Employer: Work Phone Number: Co-pay (if known): Deductible (if known):

Dental History

General Dentist: Last Visit:

How did you hear about our Practice? Ad Internet Family/Friend Physician Other
Name of person referring (if applicable) :

What are the main concerns you would like orthodontics to accomplish? Concerns:

Have you visited an orthodontist before? Yes No
When: Reason:

Have your tonsils or adenoids been removed? Yes No

Have you ever experienced jaw joint pain/ discomfort (TMJ/TMD)? Yes No

Do you have any missing or extra permanent teeth? Yes No

Have you ever had an injury to (select all that apply): Teeth Mouth Chin

Do you have speech problems? Yes No
If so, explain:

Do your gums bleed? Yes No

Do you smoke? Yes No

Do you like your smile? Yes No

Do you currently or have you ever had any of the following habits (check all that apply) Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail Biting
Thumb/Finger Sucking
Chewing/Eating Problem

Medical History

Are you currently being treated by a physician? Yes No
Reason: Physician: Last Visit: Phone:

Do you have any allergies/sensitivities to medications or latex? Yes No
If yes, please list:

Are you currently taking any prescription or over-the-counter medications? Yes No
Please list, with dosage:

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?

Yes No

Have you had any serious illnesses or operations? If yes, describe:

Have you ever had a blood transfusion? Yes No If yes, give approximate dates:

(Women) Are you pregnant? Yes No Nursing? Yes No Taking birth control pills? Yes No

Check if you have or have ever had any of the following:

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.

Submitted by: Date:

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