Adult New Patient Form

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Adult New Patient Form

New Patient Adult Form

Step 1 of 12

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Patient’s Name*
First Middle Last
Title
- Mr.
- Mrs.
- Ms.
- Miss.
- Dr.
Other
I prefer to be called
Birth Date*
Month
Day
Year
Sex
- Male
- Female
Social Security #
Marital Status
- Single
- Married
- Separated
- Divorced
- Widowed
Home Address*
Street Address Address Line 2 City State ZIP Code
Cell Phone*
Home Phone
Work Phone
E-mail address(es)
Occupation
Employer

Closest Relative
Spouse or closest relative’s name(s)
Title
- Mr.
- Mrs.
- Ms.
- Miss.
- Dr.
Other
Relationship to patient
Address (if different than patient address)
Street Address Address Line 2 City State ZIP Code
Cell Phone
Home Phone
Work Phone

Dentist
Patient’s Dentist
Address
Street Address Address Line 2 City State ZIP Code
Last seen
Reason
Next appointment
Other dentists/dental specialists now being seen:
Name
City, State
Reason
Next appointment

PHYSICIAN
Patient’s Physician
City, State
Last seen
Reason
Next appointment
Most recent physical exam
Other physicians/health care providers being seen now:
Name
City, State
Reason
Name
City, State
Reason

GENERAL INFORMATION
What concerns you about your teeth?
Who suggested that you might need orthodontic treatment?
Why did you select our office?
Have you had any previous orthodontic treatment? Please describe
Have any other family members been treated in this office? Please name them.
Do you think that any of your work or leisure activities affect your teeth or jaws? Please explain.

FINANCIAL RESPONSIBILITY
Who is financially responsible for this account?
Address(if different from page 1)
Street Address City State ZIP Code
Cell Phone
Home Phone
E-mail address(es)
Social Security #
Employer
Who will be responsible for bringing the patient to orthodontic appointments?

DENTAL INSURANCE
Primary policy holder’s full name
Birthdate
Month
Day
Year
Social Security #
Relationship to patient
Address (if not listed above)
Street Address City State ZIP Code
Phone
Employer
Insurance Company
Insurance Group #
Insurance ID#
Does this policy have orthodontic benefits?
- Yes
- No
- Don`t know
Secondary policy holder’s full name
Birthdate
Month
Day
Year
Social Security #
Relationship to patient
Address (if not listed above)
Street Address City State ZIP Code
Phone (if not listed above)
Employer
Insurance company
Insurance Group #
Insurance ID #
Does this policy have orthodontic benefits?
- Yes
- Now
- Don`t know

Have you had allergies or reactions to any of the following:
Latex (gloves, balloons)
- Yes
- No
Metals (jewelry, clothing snaps)
- Yes
- No
Acrylics
- Yes
- No
Local anesthetics (novocaine, lidocaine, xylocaine)
- Yes
- No
Aspirin
- Yes
- No
Ibuprofen (Motrin, Advil)
- Yes
- No
Penicillin
- Yes
- No
Other antibiotics
- Yes
- No
Plant pollens
- Yes
- No
Animals
Foods
Other substances
- Yes
- No
Please list any additional substances

DENTAL HISTORY

Now or in the past, have you had:
Permanent or extra (supernumerary) teeth removed?
- Yes
- No
Supernumerary (extra) or congenitally missing teeth?
- Yes
- No
Chipped or injured primary or permanent teeth?
- Yes
- No
Any sensitive or sore teeth?
- Yes
- No
Bleeding gums, bad taste or mouth odor?
- Yes
- No
Jaw fractures, cysts, infections?
- Yes
- No
Any teeth treated with root canals or pulpotomies?
- Yes
- No
“Gum boils,” frequent canker sores or cold sores?
- Yes
- No
History of speech problems or speech therapy?
- Yes
- No
Difficulty breathing through nose?
- Yes
- No
Food impaction between the teeth?
- Yes
- No
Mouth breathing habit or snoring at night?
- Yes
- No
History of speech problems?
- Yes
- No
Frequent oral habits (sucking finger, chewing pen, etc.)?
- Yes
- No
Teeth causing irritation to lip, cheek or gums?
- Yes
- No
Abnormal swallowing (tongue thrust)?
- Yes
- No
Tooth grinding or clenching?
- Yes
- No
Clicking, locking in jaw joints?
- Yes
- No
Soreness in jaw muscles or face muscles?
- Yes
- No
Ringing in ears, difficulty in chewing or opening jaw?
- Yes
- No
Have you ever been treated for “TMJ” or “TMD” problems?
- Yes
- No

PATIENT HEALTH INFORMATION

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.
Do you take antibiotic pre-medication before any dental procedures?
- Yes
- No
Medication
Taken for
Medication
Taken for
Have you ever taken any medications to strengthen your bones? Please describe.
Do you or have you ever had a substance abuse problem?
Have you chewed tobacco
- Yes
- No
or smoked any substance or vaped?
- Yes
- No
If yes, what is the frequency?
Have you noticed any changes in your face or jaws?
Any other physical problems?
How often do you brush?
How often do you floss?
Women: Are you pregnant?
- Yes
- No
Are you trying to become pregnant?
- Yes
- No

FAMILY MEDICAL HISTORY

Have your parents or siblings ever had any of the following health problems? If so, please explain.
Bleeding disorders
Diabetes
Arthritis
Severe allergies
Unusual dental problems
Jaw size imbalance
Other family medical conditions?

RELEASE AND WAIVER

I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.
Signature
Date
Month
Day
Year
I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.
Signature
Date
Month
Day
Year

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Mobile

58 Mobile Street N.
Mobile, AL 36607

(251) 479-9597
Mobile

801 S. University Boulevard
Building B-2
Mobile, AL 36609

(251) 479-9597
Mobile

1059 Snow Road S.
Building A
Mobile, AL 36695

(251) 479-9597

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Our Locations

Mobile Street
58 Mobile Street N.
Mobile, AL 36607
(251) 479-9597
___

University Boulevard
801 S. University Boulevard
Building B-2
Mobile, AL 36609
(251) 479-9597
___

Snow Road
1059 Snow Road S.
Building A
Mobile, AL 36695
(251) 479-9597

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Friday: CLOSED

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Adult New Patient Form

New Patient Adult Form

Step 1 of 12

Dentist

PHYSICIAN

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

DENTAL HISTORY

PATIENT HEALTH INFORMATION

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER

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