Adult Patient Form

SAVE TIME! Please use the form below to fill out your patient information online and you will be able to submit a copy directly to our office, as well as print a copy for your records.

This is an ONLINE FORM. Please fill out the following form as completely as possible. Fields marked with an asterisk are required. Once you have filled out the application you will be able to save/preview a copy and then submit the form securely to our office. After you have completed the form please check the information for accuracy and then click the submit button at the bottom of the page. If you prefer to print the form out, complete it by hand and submit it manually to us, click here.

SSL Encrypted for your protection, look for this lock symbol to ensure your page is encrypted and secureFor your safety this page has been encrypted. This ensures all data (including sensitive personal information) is SSL encrypted so that communications cannot be intercepted and misused by unauthorized parties.

PATIENT INFORMATION

Name *
Residence
Full Mailing Address * (Street Address, City, State, Zip)
 Years at This Address
Previous Address (if less than 3 years) (Street Address, City, State, Zip)
Home Phone
Work Phone
Cell Phone
Social Security Number
 Date of Birth
 Email *
Employer
 Occupation
 Years Employeed
Who may we thank for referring you?
 General Dentist
Spouse's Information
Name
 Date of Birth
Home Phone
Work Phone
Social Security Number
Relationship to Patient
 Responsible Party

ORTHODONTIC INSURANCE INFORMATION

Insured's Name
 Date of Birth
 Insured's Social Security #
Insurance Company
 Group #
 Policy #
Insurance Company Address (Street Address, City, State, Zip)
Do you have dual coverage? Yes No     If yes, please fill out secondary insurance info below:
Insured's Name
 Date of Birth
 Insured's Social Security #
Insurance Company
 Group #
 Policy #
Insurance Company Address (Street Address, City, State, Zip)
1st Insured's Employer
 2nd Insured's Employer

GENERAL DENTAL HISTORY

What are your chief concerns?
Describe what you would like orthodontics to accomplish.
Have you been evaluated or had orthodontic treatment? Yes No
Have you had a serious/difficult problem associated with any previous dental work? Yes No
Have there been any injuries to your face, mouth, or chin? Yes No
Do your gums ever bleed? Yes No
Have you ever had any pain/tenderness in your jaw joint (TMJ/TMD)? Yes No
Are you now or have your ever been treated for periodontal disease? Yes No
If yes, please explain:
Do you generally breath through your mouth? Yes No
If yes, when do you breathe through your mouth?
When Awake    When Asleep
Have you been informed of any missing or extra permanent teeth? Yes No
Please describe your current physical health
Good    Fair    Poor

ADULT MEDICAL HISTORY

Are you currently under the care of a physician? Yes No
If yes, please explain:
Please list any medications/drugs that you are taking:

Allergies
Aspirin Yes No Any metals/plastics Yes No
Latex Yes No Codeine Yes No
Dental Anesthetics Yes No Erythromycin Yes No
Penicillin Yes No Tetracycline Yes No
Other Allergy 1 Other Allergy 2
Do you need to take medication before seeing the dentist? Yes No
If yes, what?

Have you ever had any of the following?
Abnormal Bleeding Yes No Mitral Valve Prolapse / Heart Murmur Yes No
Allergies to any drugs Yes No Hemophilia Yes No
Congenital Heart Defect Yes No HIV+ / Aids Yes No
Diabetes Yes No Hepatitis / Liver Disease Yes No
Tuberculosis(TB) Yes No Allergic to Latex / Metals Yes No
Convulsions / Epilepsy Yes No Allergic to Plastic Yes No
Handicaps / Disabilities Yes No

EMERGENCY INFORMATION

Name of nearest relative not living with you
 Relationship
Complete Address (Street Address, City, State, Zip)
 Phone
Get the care you need with our flexible payment options. Click here to learn more.