Adult Form

Patient Information

First Name*

Middle Name

Last Name*

Preferred Name

Gender*
MaleFemale

Date of birth*

Best Phone Number*
Phone Type

Alternate Phone Number

Email Address*

Marital Status

Spouse’s Name (if applicable)

Home Address

Street*

City*

State*

Zip/Postal Code*

Family Dentist (if you have one):

How did you hear about our office (friend, cousin, Google search, dentist, etc)*:

Please list any family members seen by us:

Financially Responsible Party Information (Who would be responsible for paying)

Will somebody else other than the patient be responsible Financially?

yes

Relationship to Patient*

First Name*

Last Name*

Gender
MaleFemale

Birth Date

Home Address*

Check if Address Same as Above Address

Street*

City*

State*

Zip/Postal Code*

Best Phone Number

Alternate Phone Number

Email Address*

Marital Status

Spouse’s Name (if applicable)

Please check if there is a second responsible party

yes

Relationship to Patient*

First Name*

Last Name*

Gender
MaleFemale

Birth Date

Home Address

Check if Address Same as Above Address

Street*

City*

State*

Zip/Postal Code*

Best Phone Number*

Alternate Phone Number

Email Address*

Marital Status

Spouse’s Name (if applicable)

Dental Insurance Information

Check if yes have insurance

Primary Policy Holder's First Name*

Primary Policy Holder's Last Name*

Insurance Company*

Insurance Company Phone Number

Subscriber's Birth Date

Subscriber's Employer*

Subscriber/Member ID Number

Subscriber's Social Security Number (U.S. only)

Do you have Dual coverage:

yes

Secondary Policy Holder's First Name*

Secondary Policy Holder's Last Name*

Insurance Company*

Insurance Company Phone Number

Subscriber's Birth Date

Subscriber's Employer*

Subscriber/Member ID Number

Subscriber's Social Security Number (U.S. only)

Medical History

Now or in the past, has the patient had:
Attention Deficit DisorderAllergy to LatexArthritisBehavioral problemsBirth Defects or Hereditary ProblemsBone or Joint DisorderDiabetesEpilepsy or ConvulsionsFainting or DizzinessFrequent Headaches or MigrainesGagging or nausea problemsGrowth or Endocrine ConditionHearing DisorderHeart DisorderPsychiatric Treatment or Psychological Disorder

Patient is pregnant
YesNo

Any Medications patient is currently taking:

Have tonsils or adenoids been removed:
YesNo

if so what age:

Any other medical conditions we should be aware of:

Any known Allergies:

I have read and understand the above questions. 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. If there are any changes later to this history record or medical/dental status, I will so inform this practice.

Patient/Legal Guardian Electronic Signature:

Please enter your full name*

Today's date*

Patient Information

Financially Responsible Party Information (Who would be responsible for paying)

Will somebody else other than the patient be responsible Financially?

Home Address*

Please check if there is a second responsible party

Home Address

Dental Insurance Information

Do you have Dual coverage:

Medical History

Dental History

Schedule An Appointment

Schedule An Appointment

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