New Patient Registration

Patient Information

Patient's Name

Date

Date of Birth

Age

Address

City

State

Zip code

Home Phone No.

Cell Phone No.

Email address

Dentist

City

School

Hobbies

List Siblings with age

Your name & relationship to patient:

Whom may we thank for referring you?

Patient Dental History

What are the main concerns you would like orthodontics to accomplish?

When was your last dental visit?

Responsible Party Information

(If different from Section 1)

Name

Relation

Date of Birth

Billing Address

City

State

Zip

Cell Phone No.

Rsp. Email

Occupation

Employer

Years

Spouse Name

Relation

Date of Birth

Cell Phone No.

Occupation

Employer

Years

Insurance Information

Add new row

Emergency Information

Name of nearest relative or neighbor

Relation

Phone No.

Address

City

State

Zip

Patient Medical History

Physician Name

Phone No.

Address

City

State

Zip

When was your last physical?

Please elaborate on any of the above, where necessary

List any serious medical condition(s) you have had, NOT listed above

If yes, please describe

Allergies

Please list any other drugs / materials that you are allergic to

Drugs & Medications

Please list all prescription and non-prescription drugs taken or used in the past three months:

Thank you for filling out this form completely.

By signing, I agree that the information I have given today is correct to the best of my knowledge. I also understand that this information is held in the strictest confidence, as described in the Notice of Privacy Practices given to me. I recognize that it is my responsibility to inform this office of any changes in my medical status. I understand that when appropriate, credit bureau reports may be obtained. Furthermore, I authorize this staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Responsible Party Name / Signature

Date

Your information will be encrypted.

New Patient Registration

Patient Information

Patient Dental History

Responsible Party Information

Insurance Information

Emergency Information

Patient Medical History

Allergies

Drugs & Medications

Thank you for filling out this form completely.

NAGEL ORTHODONTICS