Adult Form

Patient Information



MaleFemale






Home Address








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

Will somebody else other than the patient be responsible Financially?

yes





MaleFemale

Home Address*

Check if Address Same as Above Address










Please check if there is a second responsible party

yes





MaleFemale

Home Address

Check if Address Same as Above Address










Dental Insurance Information

Check if yes have insurance









Do you have Dual coverage:

yes









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


YesNo


YesNo



Dental History


YesNo


YesNo


YesNo


YesNo


YesNo


YesNo


YesNo

YesNo

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: