Adult New Patient Information

SHARE:
Patient form (same for child and adult)

Patient Information

Gender *




Primary Phone Number *






Primary Responsible Party Information







Phone Number
Secondary Phone Number



Secondary Responsible Party Information







Phone
Secondary Phone Number




Insurance Information





















Emergency Contact (Not residing with Patient)








Dental History



Any pain, clicking or discomfort in the ears? *
Any serious injury to the patient's mouth, face, teeth? *
Have you ever had an injury to (select all that apply): *
Are you aware of any gum problems?
Has a physician or dentist advised andtibiotics before a dental exam? *
Have the patients' tonsils or adenoids been removed? *
Has the patient been examined by an orthodontist before? *


In your own words, what is the orthodontic problem of patient? *
What would you like orthodontic treatment to accomplish? *
Is the patient / are you happy with his / her smile? *
Is the patient comfortable with the idea of wearing braces? *

Patient Medical History

Check if the patient has or has ever had any of the following:
Is the patient currently being treated by a physician? *

Is the patient currently taking any prescription or over-the-counter medications? *
Does the patient have any allergies/sensitivities to medications or latex? *
Has the patient had any serious illnesses or operations? If yes, describe:
Is the patient addicted to any drugs? *
Is the patient pregnant at this time? *
Does the patient currently smoke? *
Is the patient of normal height? *
Is the patient of normal weight? *
Is the patient past puberty? *
Has the patient had surgery? *

Is there any social interaction disorder (for example; Autism, Aspergers) that we should be aware of in order to make the patient more comfortable? *

Are you aware of any other disease, condition, or problem not listed above that we should know about? *

Other Helpful Information


How did you hear about Star Orthodontics? *

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.




Security Measure