Adult new patient form

"*" indicates required fields

Patient Information

Sex:

Birth Date:
Patient's Address:

Emergency Contact Information

Referral Information

Primary Insurance Information

Policy Holder's Date of Birth:

Secondary Insurance Information

Policy Holder's Date of Birth:

Dental History

Have you visited an orthodontist before?
Have your tonsils or adenoids been removed?
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Do you have any missing or extra permanent teeth?
Have you ever had an injury to (select all that apply):
Do you have speech problems?
Do your gums bleed?
Do you smoke?
Do you like your smile?
Do you currently or have you ever had any of the following habits (check all that apply):

Medical History

Are you currently being treated by a physician?*
Do you have any allergies/sensitivities to medications or latex?*
Are you currently taking any prescription or over-the-counter medications?*
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)?*
Have you ever had a blood transfusion?*
(Women) Are you pregnant?*
Nursing?*
Taking birth control pills?*
Check if you have ever had any of the following:

Authorization

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.
Date