Adult New Patient Intake Form at Georgetown Orthodontics

Today's Date

Name

First Middle Last

Name you prefer to be called

Home Address*

Street Address Address Line 2 City State ZIP Code

Billing Address (if different from Home Address)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Birth Date*

Age*

Gender

Male

Female

Email Address*

Enter Email Confirm Email

Do you wish to receive appointment reminders and updates to this address?

Yes

Cell Phone Number*

Do you wish to receive texted appointment reminders and updates to this number?

Yes

Home Phone Number

Employer*

Work Phone Number

Whom may we thank for referring you?

General Dentist Name*

Last Visit date to Dentist (approximate)*

Insurance / Billing Information

INSURANCE – Do you have orthodontic coverage?*

Yes

Insurance Company Name

Insurance Company Address

Street Address Address Line 2 City State ZIP Code

Insurance Company Phone Number

Group Number (Plan, Local or Policy #)

Member/Subscriber ID#

Policy Owner's Name

First Last

Relationship to You

Policy Holder's Social Security Number (required to file some insurances)

This is a secure site and all information will be kept strictly confidential.

Policy Owner's Birthdate

Policy Owner's Employer

Employer's Address

Street Address Address Line 2 City State ZIP Code

Objectives and Patient Medical Information

What are the main concerns that you would like orthodontics to accomplish?

Have you ever been evaluated for orthodontic treatment before?

Yes

Have you ever had orthodontic treatment with another doctor?

Yes

If you have had previous orthodontic therapy please give a brief description and approximate dates of treatment:

Have there been any injuries to your face, mouth, teeth, or chin?

Yes

If you answered yes, please give a brief description

Have your adenoids or tonsils been removed?*

Yes

Have you been informed of any missing or extra permanent teeth?*

Yes

Have you ever had any pain/tenderness in your jaw joint (TMJ/TMD)?*

Yes

Are you currently under the care of a physician?*

Yes

Physician's Name

First Last

Physician's Phone Number

Date of Last Visit (approximate)

Please describe your current physical health:*

Good

Fair

Poor

Please list all prescribed and over the counter medications that you are currently taking:*

Please list all medication and/or food allergies:*

Allergic to Latex?*

Yes

Allergic to Metals/Nickel?*

Yes

Allergic to Plastics?*

Yes

Please check any of the following medical problems that you have ever had:*

Please discuss any medical problems that you have had:

Please check any of the following that you have ever experienced:*

Clenching / Grinding Teeth

Lip Sucking / Biting

Mouth Breather

Nail Biting

Nursing Bottle Habits

Speech Problems

Thumb / Finger Sucking

Tongue Thrust

None

Notice of Privacy Practices*

Your trust and privacy are paramount to us as we strive to provide exceptional dental services. This privacy policy is designed to inform you about how we handle personal information collected through our website and in-office: We collect information that you choose to provide to us through emails or direct contact. This information is under our sole ownership and is never sold or distributed. We utilize your information primarily to respond to your inquiries and fulfill your requests, ensuring you receive top-notch dental care. We only share your information with entities outside our organization when necessary to deliver these services or as required by law. With your consent, we may occasionally inform you about our special offers, new products or services, or changes to this privacy policy. You have the right to restrict how your protected health information is used and disclosed. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. By signing this form, I understand that: A. Protected health information may be disclosed or used for treatment, payment, or healthcare operations. B. The practice reserves the right to change the privacy policy as allowed by law. C. The patient/legal guardian has the right to restrict the use of the information and shall inform the office in writing as to what PHI they wish to restrict, if applicable. D. The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.

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 my medical status.*

Name

This field is for validation purposes and should be left unchanged.

Additional Topics

Adult New Patient Intake Form

Adult New Patient Form

Insurance / Billing Information

Objectives and Patient Medical Information