Dr. Neal Patel, DMD, MS
Dr. Bhaven Sayania, DMD, MS
5614 Potter Road, Suite A
Matthews, NC 28104
www.sporthodontics.com
704-594-7171
ADULT WELCOME FORM
Date
Patient name
Preferred Name
Gender
Age
Birth date
Email
Address
(city, state, zip)
Best number to be contacted at
Cell
Home
Other
Occupation
Employer
EMERGENCY Contact/Relation
Phone Number
Whom may we thank for recommending our office to you? (Please check all that apply)
Google
Facebook/Instagram
Dentist
Family/Friends
Other
Past or Present Family Members in Treatment
Have you consulted an orthodontist previously?
Financial Information
self (if self, skip to next section)
Financially Responsible Party
Relationship to patient
Address
(city, state, zip)
Best number to be contacted at
Birth date
Occupation
Employer
Medical/Dental
Dentist
Date of Last Dental Cleaning
Past or current history of Smoking or Tobacco use?
Yes
No
Now or in the past, has the patient had:
Yes
No
Abnormal bleeding/Hemophilia
Yes
No
AIDS/HIV+
Yes
No
Asthma/Breathing Problems
Yes
No
Bone /Joint Disorders
Yes
No
Cancer /Chemotherapy/Radiation
Yes
No
Diabetes
Yes
No
Epilepsy
Yes
No
Permanent teeth removed or congenitally missing teeth
Yes
No
Server head or face injuries
Yes
No
Frequent oral habits(sucking finger, tongue thrust, chewing pen, etc.)
Yes
No
Tooth grinding or clenching
Yes
No
Clicking, locking, or soreness in jaw joints(TMJ)
Please explain any medical/dental items checked 'yes'
Please list any other relevant medical conditions and/or allergies:
Patient taking any medications?
Yes
No
If yes, please list:
Please rate the following aspects of your orthodontic treatment in terms of their importance to you:
1) The comfort of the appliances used
Not Important
Slightly Important
Moderately Important
Important
Very Important
2) Esthetic or clear appliances (clear braces vs metal braces vs clear aligners)
Not Important
Slightly Important
Moderately Important
Important
Very Important
3) Low monthly payments
Not Important
Slightly Important
Moderately Important
Important
Very Important
4) Ability to begin treatment within the next 30 days
Not Important
Slightly Important
Moderately Important
Important
Very Important
I, the undersigned, have given the above information and certify that it is accurate. I have also received a copy of the Notice of Privacy Practices for Orthodontic Associates.
Signature
Date
I authorize the release of medical, dental, and/or financial information to the following:
1
Relationship to Patient:
2
Relationship to Patient:
3
Relationship to Patient: