Form

Orthodontic New Patient Acquaintance Form

In this section are confidential forms that area very important. Please take the necessary time to accurately fill them out.

We suggest that this be done when you are not rushed and can candidly reveal any concerns regarding the patient's orthodontic care. The more we know about him or her, the better we'll be able to serve you.

Please submit this form digitally as soon as possible, and at minimum 48 hours prior to your appointment.

Patient's First Name

Middle Name

Last Name

Gender

Date Of Birth

Name of Referring Dentist

Are any other family members seen with our orthodntics

What questions/issues/concerns would you like addressed today?

Has the patient had any negative dental experiences?

Please explain this experience

Whom may we thank for referring you to the office?

MEDICAL INFORMATION

Patient's Primary Care Provider (PCP)

Address City, State

Phone

Is the patient in good health

Are the patients immunizations up to date?

Is the patient being treated for any condition presently?

Please explain below:

Is the patient taking any medication, supplement, vitamins etc.?

Please explain below:

Has the patient ever been hospitalized or had surgery?

Please explain below:

Does the patient have any allergies?

Please explain below:

Has the patient had any history or difficulty with any of the following conditions?

Please give additional details for any of the selected conditions above:

Please describe any current or past medical treatment including drugs, pending surgery, recent injuries or any other information that has not been covered on the list of medical conditions above. IF NO ISSUES WRITE NONE

DENTAL INFORMATION

Does the patient brush daily?

Does the patient floss daily?

Does the patient have any of the following mouth habits?

Explain habit:

Does the patient receive fluoride in any of the following forms?

Dosage (if known)

GENERAL INFORMATION

Parent's (Guardian's) Full Name

Birthdate

Address

City, State

Zip

Home Phone

Occupation

Employed by

Business Phone

Cell phone

Parent's (Guardian's) Full Name

Birthdate

Address (if different)

City, State

Zip

Phone

Occupation

Employed by

Business Phone

Cell phone

Marital Status

Patient lives with:

Please explain Other:

DENTAL INSURANCE

**Please note that we file insurance for the primary carrier only**

Do You Have Dental Insurance?

Subscriber's Name

Date Of Birth

Employer's Name

Subscriber's ID

Group #

Insurance Carrier

Carrier's Phone Number

Carrier's Address

I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform the office of any change’s in the patient's medical status. I authorize the dental staff to perform the dental services the patient may need.

Signature

Date

Relationship to Patient