Adult New Patient Information

Adult Registration Form - Dental
* required field

Patient Information

Gender Male Female






Primary Phone Number

Home Cell
Secondary Phone Number

Home Cell Other




Are the patient's immunizations current? Yes No

Responsible Party Information



Responsible Party Marital StatusSingle Married Divorced Widowed Significant Other







Responsible Party Primary Phone Number
Home Cell
Responsible Party Secondary Phone Number
Home Cell



Emergency Contact Information










Insurance Information


























Dental History



What are the main concerns you would like orthodontics to accomplish?
Have you visited an orthodontist before? Yes No

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
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?

Medical History

Are you currently being treated by a physician? Yes No



Do you have any allergies/sensitivities to medications or latex? Yes No

Are you currently taking any prescription or over-the-counter medications? Yes No

Has puberty and/or menstruation begun? Yes No
Have you had any serious illnesses or operations? Yes No
Have you ever had a blood transfusion? Yes No

Yes No

Yes No

Yes No
Check if you have or 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.




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