Adult New Patient Information

Adult Registration Form - Ortho
* required field

Patient Information


Primary Phone Number
Secondary Phone Number

Spouse/Emergency Contact Information

Marital Status

Person(s) OK to release appointment or medically related information to concerning you

Dental 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)?
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?

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 had any serious illnesses or operations? If yes, describe
Have you ever had a blood transfusion?
Women


Check if you have or have ever had any of the following

Authorization and HIPAA Notice of Privacy Practices

I give this practice my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for healthcare operations like quality reviews.

I've been informed that I may review the practice Notice of Privacy Practices (For a more complete description of uses and disclosures) before signing this consent.

I understand that the practice has the right to change their privacy practices and I may obtain any revised notice of the practice.

I understand that I have the right to request a restriction of how my protected health information is used. However I also understand that the practice is not required to agree to the request. If the practice agrees to my requested restriction, they must follow the restriction(s).

I also understand that I may revoke this consent at any time, by making a request in writing, except for information already used or disclosed.

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