Adult New Patient Form

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

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.

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

Dentist