Patient Form Adult

PATIENT INFORMATION FOR PATIENTS UNDER 18 YEARS OF AGE

Patient’s name

Address

City

State

Zip Code

Cell Phone No.

Birthdate

Social Security #

Email address

Parent or guardian name

Whom may we thank for referring you to our office?

RESPONSIBLE PARTY INFORMATION

Name

Mailing Address

Residence

How long at this address?

Home Phone No.

Work Phone No.

Cell Phone No.

Email address

Previous Address (If less than 3 years)

Birthdate

Social Security #

Relationship to Patient

Employer

Occupation

No. years employed

Spouse’s Name

Relationship to Patient

Employer

Occupation

No. years employed

Social Security #

Birthdate

Work Phone No.

Whom may we thank for referring you to our office?

DENTAL INSURANCE INFORMATION

Insured’s Name

Insured’s Social Security #

Insurance Company

Group No

Local No.

Insurance Co. Address

Phone No.

If yes

Insured’s Name

Insured’s Social Security #

Insurance Company

Group No.

Local No.

Insurance Co. Address

Phone No.

EMERGENCY INFORMATION

Name of nearest relative not living with you

Complete address

Phone No.

I understand that, where appropriate, credit bureau reports may be obtained.

DISCLAIMER: 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.

Signature (Parent’s signature if minor)

Date

MEDICAL HISTORY

Physician

Date of Last Visit

Address

Phone No.

If Yes, please fill in details

If yes, Why?

Are there any medical conditions we have not discussed that you feel we should be aware of?

DENTAL HISTORY

General Dentist

Date of last visit

What concerns you most about your teeth?

If yes, Please explain

Where

If yes, Please explain

If yes, who and when?

How did they feel about the result?

If yes, Please explain

Mom

Dad

Please list some hobbies or interests

Female Patients only

BENEFITS

Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history.

In addition, I authorize Dr

to perform a complete orthodontic evaluation.

DISCLAIMER: 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.

Signature

Date

Your information will be encrypted.

Patient Form Adult

PATIENT INFORMATION FOR PATIENTS UNDER 18 YEARS OF AGE

RESPONSIBLE PARTY INFORMATION

DENTAL INSURANCE INFORMATION

EMERGENCY INFORMATION

MEDICAL HISTORY

DENTAL HISTORY

BENEFITS

Braceland Orthodontists