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New Patient Form – Adult
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2022-03-14T15:52:14+00:00
New Patient Information - Adult
This form is to be used for patients 18 or over.
Please enable JavaScript in your browser to complete this form.
Patient Information
Patient Name
*
Nickname or Preferred Name
Patient Date of Birth
*
Patient's Age
*
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Email
*
Other family members treated at our office:
Who referred you to our office?
*
Name of dentist:
Approximate date of last visit:
Next
Responsible Party Information
Dental Insurance Company
Dental Insurance Company Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Dental Insurance Company Phone Number
Policy/Group ID
Subscriber Name
First
Last
Subscriber Employer
Subscriber Date of Birth
Subscriber SSN or ID
Next
Medical History
For the following questions, circle yes or no, whichever applies. Your answers are for our records only and will be considered confidential. Please note that during your initial visit you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.
Physician Name
First
Last
Date of Last Visit
Current Physical health is:
*
Good
Fair
Poor
Have Tonsils or Adenoids been removed?
*
Yes
No
Are you taking prescription/over-the-counter medications?
Yes
No
Please list all medications and reason for prescription:
Have you ever had any of the following medical problems or diseases?
Abdominal bleeding/Hemophilia
Anemia
Artificial Bones/Joints/Valves
Asthma
Blood Transfusion
Cancer/Chemotherapy
Congenital Heart Defect
Difficulty Breathing
Colitis
Diabetes
Emphysema
Epilepsy
Fainting Spells
Frequent Headaches
Glaucoma
Hay Fever
Heart Attack/Surgery
Heart Murmur
Hepatitis
Herpes/Fever Blisters
High Blood Pressure
HIV/AIDS
Kidney Problems
Latex Allergy
Liver Disease
Low Blood Pressure
Lupus
Mitral Valve Prolapse
Nickel Allergy
Psychiatric Problems
Rheumatic/Scarlet Fever
Shingles
Sinus Problems
Thyroid Problems
Prosthetics
Radiation Treatment
Seizures
Sickle Cell Disease
Stroke
Tuberculosis
Any Hospitalization
Do you have any of the following habits?
Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail Biting
Speech Problems
Thumb/Finger Sucking
Tongue Thrust
Pacifier Usage
Please list any known allergies:
Next
Have you ever been evaluated for orthodontic treatment?
*
Yes
No
Have you ever experienced pain or discomfort in the jaw joint (TMJ/TMD)?
*
Yes
No
Have you ever had an injury to your: (Select all that apply)
Mouth
Teeth
Chin
Attestation
I understand that the information provided in this form is correct to the best of my knowledge. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent. I understand that I am responsible for payment of services rendered and for any co-payment that my insurance does not cover, including the deductible. I understand that I am responsible for all costs of orthodontic treatment. I herby authorize release of any information, including the diagnosis and records of treatment or examination rendered to my insurance company.
Signature or Parent or Guardian
*
Clear Signature
Phone
Submit
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