New Patient Registration

Adult Registration Form - Ortho
* required field

Patient Information

Gender




Primary Phone Number
Secondary Phone Number

Responsible Party (if patient is a minor)










Primary Insurance Information
















Dental History


How did you hear about our Practice?
What are the main concerns you would like orthodontics to accomplish?
Have you visited an orthodontist before?

Have your tonsils or adenoids been removed?
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
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 currently or have you ever had any of the following habits?

Medical History

Are you currently being treated by a physician?



Do you have any allergies to medications, latex or metals?
Are you currently taking any prescription or over-the-counter medications?
Have you had any serious illnesses or operations? If yes, describe:
(Women)




Check if you have or have ever had any of the following:
Have you had any unusual reactions to the following drugs?


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