Adult New Patient Form Submit your health history form online to your orthodontist today. Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form and click "submit". Your information will be sent to our office with secure encryption. We will have your information when you arrive for your first appointment.Patient InformationName* First Middle Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Sex*MaleFemaleBirthdate* Date Format: MM slash DD slash YYYY Social Security #Home Phone*Cell Phone*EmployerWork PhoneEmail Spouse's NameSpouse's EmployerDentistReferred By:Additional InformationReason for Appointment*List family members that have been treated by this practiceHave you had previous orthodontic treatment?YesNoIf Yes, whenHave there been any injuries to the face, mouth, teeth or chin?*YesNoHave you had problems with previous dental treatment?*YesNoHave you been treated by a periodontist?*YesNoHave you ever had a fractured jaw?*YesNoHave you been treated for TMJ?*YesNoDo you need to be pre-medicated before dental treatment?*YesNoWhat is the primary concern for your orthodontic evaluation?SO THAT WE MAY BETTER SERVE YOU, PLEASE FILL OUT THE QUESTIONNAIRE BELOW.When choosing orthodontic treatment, what is important to you? Please rank the options below with 5 being extremely important and 1 not important.1= Not Important 2= Somewhat important 3= Important 4= Very Important 5= Extremely important Length of treatment12345Comfort during treatment12345Using the latest technology12345As aesthetics of treatment (clear braces or Invisalign)12345A low initial fee12345A low monthly fee12345Quality of treatment12345If treatment is recommended, how interested are you in starting treatment today or within the next 30 days?12345Whom may we thank for referring you to our office? My Dentist Friend Google Yelp Community Service Family Member Facebook Instagram Other Please Specify:MEDICAL HISTORYPatient Name First Last Birth Date Date Format: MM slash DD slash YYYY Physician’s NameDate of Last VisitAre you in good health?YesNoPlease explain:Are you taking any medications (include over-the counter)?YesNoIf yes, please list each drug:Do you have a history of any of the following?Abnormal Bleeding*YesNoAcquired Immune Disorder*YesNoAIDS/HIV*YesNoAnemia*YesNoArthritis*YesNoArtificial Joints or Valves*YesNoAsthma*YesNoBlood Disorders*YesNoBlood Transfusions*YesNoCancer*YesNoCleft lip/ Palate*YesNoDiabetes*YesNoDifficulty Breathing*YesNoDrug/Alcohol Abuse*YesNoEmotional/Behavior Problems*YesNoEpilepsy/Seizures*YesNoHeart Disorders*YesNoHepatitis*YesNoHospitalization*YesNoKidney Disorders*YesNoLung Disorders*YesNoMigraines*YesNoMitral Valve Problems*YesNoPsychiatric Problems*YesNoRadiation Treatment*YesNoRheumatic/Scarlet Fever*YesNoSeasonal Allergies*YesNoSeizures*YesNoSickle Cell Anemia*YesNoSinus Problems*YesNoSleep Problems*YesNoSpeech/Hearing Problems*YesNoSurgery*YesNoTonsils/Adenoids/ Sinus Problems*YesNoTuberculosis (TB)*YesNoUlcers/Colitis*YesNoVision/Hearing*YesNoPlease discuss any medical problems:Have adenoid and/or tonsils been removed?YesNoIf yes, when:Are you allergic to any of the following?Anesthetics*YesNoAspirin*YesNoAmoxicillin*YesNoCodeine*YesNoCyclosporins*YesNoErythromycin*YesNoLatex*YesNoMetal*YesNoPenicillin*YesNoSulfa Drugs*YesNoTetracycline*YesNoPlease list any other medicine or material you may be allergic to:Explain any Yes answers aboveList daily medications you are presently taking:DENTAL HISTORYDate of last dental visit:Have you ever had complications following dental treatment?YesNoDo you currently have cavities/toothaches that need treatment?YesNoAny Clicking/ Popping or Jaw pain?YesNoGrind or clench teeth day or night?YesNoEver injured any teeth?YesNoEver injured jaws or face?YesNoDo you need to be pre-medicated before dental treatment?YesNoHave had tonsils/adenoids removed?YesNoRealizing that successful treatment greatly depends upon your cooperation in following instructions, keeping appointments, and maintaining oral hygiene. Are there any restriction, handicaps, or problems that might be encountered during treatment?*YesNoIf yes, please explainSignatures* I understand that the information that 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 this office of any changes in the patient's medical status. I authorize the dental staff to perform the necessary dental services I/my child may need. * I authorize this office to verify my/my child's insurance benefit prior to my appointment. * If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. * I understand that at the time of my office visit, my physical signature will be required to confirm the acknowledgements above. SignatureOur office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.Please check your form to make sure it is complete and press the submit button when you are done. You will see a confirmation page when your form has been successfully submitted. Thank you!