Adult Patient Information

Adult Ortho Form
* required field

Patient Information






Primary Phone Number
Secondary Phone Number



Spouse/Emergency Contact Information

Marital Status









Insurance Information


























Dental History

How did you hear about our Practice?
Have your tonsils or adenoids been removed?
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Do you have any missing or extra permanent teeth?
Have you ever had an injury to (select all that apply):
Do you have speech problems?
Do your gums bleed?
Do you smoke?
Do you like your smile?
Do you currently or have you ever had any of the following habits?

Medical History

Are you currently being treated by a physician?



Do you have any allergies/sensitivities to medications or latex?
Are you currently taking any prescription or over-the-counter medications?
Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Have you had any serious illnesses or operations? If yes, describe:
Have you ever had a blood transfusion?
(Women)




Check if you have or have ever had any of the following:

Authorization

I acknowledge and understand that I am responsible for all of the charges for services rendered and that it is my responsibility to inform this office of any changes in my medical status. Although I requested that services be billed to the responsible organization on my behalf, I clearly understand that it is my responsibility to make sure the bill is paid in a responsible amount of time. If for any reason any portion of my bill is not paid by the responsible organization I further agree to make arrangements for prompt payment of the bill. I understand all aspects of my account will be held in the strictest of confidence. I further authorize this office to obtain a credit report if necessary.




Security Measure