Adult New Patient Intake Form

Adult New Patient Form

"*" indicates required fields

MM slash DD slash YYYY
Home Address*
Billing Address (if different from Home Address)
MM slash DD slash YYYY
Email Address*

Insurance / Billing Information

INSURANCE – Do you have orthodontic coverage?*
Insurance Company Address
Policy Owner's Name
This is a secure site and all information will be kept strictly confidential.
MM slash DD slash YYYY
Employer's Address

Objectives and Patient Medical Information

Have you ever been evaluated for orthodontic treatment before?
Have you ever had orthodontic treatment with another doctor?
Have there been any injuries to your face, mouth, teeth, or chin?
Have your adenoids or tonsils been removed?*
Have you been informed of any missing or extra permanent teeth?*
Have you ever had any pain/tenderness in your jaw joint (TMJ/TMD)?*
Are you currently under the care of a physician?*
Physician's Name
Please describe your current physical health:*
Allergic to Latex?*
Allergic to Metals/Nickel?*
Allergic to Plastics?*
Please check any of the following medical problems that you have ever had:*
Please check any of the following that you have ever experienced:*
This field is for validation purposes and should be left unchanged.