Adult Patient Form

Please fill out this form completely, it is important for your dental care. Our goal is to help you reach and maintain good oral health.

ABOUT YOU

Today’s Date

Full Name

Date of Birth

Age

What gender do you identify as?

Male Female Other

What gender do you identify as?

What are the patients preferred pronouns?

Home Address

City

State

Zip Code

Marital Status

Single Married Divorced Widowed Separated

Home Phone No.

Cell Phone No.

Work Phone No.

Email address

Employer

How long there?

Occupation

What time is best to reach you?

Whom may we thank for referring you?

Other family members seen by us

Dentist Name

Date of Last Visit

Previous Present

Person Responsible for Account

SPOUSE INFORMATION

Name: (Last, First, MI)

Employer

Phone No.

Birthdate

Relationship

Cell Phone No.

Emergency Contact: Relative or friend

DENTAL INSURANCE • PRIMARY

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DENTAL INSURANCE • SECONDARY

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MEDICAL HISTORY

Physician’s Name

Phone No.

Date of Last Visit

Please explain

Please list each one

If so, when?

WOMEN

Please list any serious medical condition(s) not listed above

Are you allergic to any of the following?

Aspirin

Codeine

Dental Anesthetics

Erythromycin

Latex

Penicillin

Tetracycline

Other

If selected "Other" what are your other allergies?

DENTAL HISTORY

What would you like orthodontic treatment to accomplish?

If not, what would you change?

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 that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent.

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.

Name / Signature

Date

Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

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