Bellaire Family Orthodontics Adult Questionnaire Form

MEDICAL HISTORY

Please check no or yes to the following and indicate the year

Do you require antibiotic premedication prior to dental appointments?

No Yes

RESPONSIBLE PARTY INFORMATION

Name

Residence

Mailing Address

How long at this address

Home Phone

Work Phone

Social Security #

Birthdate

Relationship to Patient

Employer

Occupation

No. Years Employed

Spouse’s Name

Employer

Occupation

No. Years Employed

Social Security #

Birthdate

Work Phone

Emergency contact person

Name

Home Phone

Work Phone

ORTHODONTIC INSURANCE INFORMATION

Insurance Company

Group No.

Local No.

Insurance Co. Address

Insured’s Name

Insured’s Soc. Sec. #

Insured’s Employer

Do you have dual coverage?

No Yes

If Yes:

Insurance Company

Group No.

Local No.

Insurance Co. Address

Insured’s Name

Insured’s Soc. Sec. #

Insured’s Employer

I understand that where appropriate, credit bureau reports may be obtained.

I give permission for x-rays and photographs to be used for research/educational purposes

GET ACQUAINTED QUESTIONNAIRE
ADULT

Vladimir Tabakman, D.D.S., M.S. | David Wadler D.D.S., M.S.

Specialist in Orthodontics for Children and Adults

How else did you hear about us? (Check all that apply)

DENTAL HISTORY

Do you:

Do you have:

ATTITUDE TOWARD TREATMENT

MEDICAL HISTORY

RESPONSIBLE PARTY INFORMATION

ORTHODONTIC INSURANCE INFORMATION

I understand that where appropriate, credit bureau reports may be obtained.

GET ACQUAINTED QUESTIONNAIREADULT

Vladimir Tabakman, D.D.S., M.S. | David Wadler D.D.S., M.S.

Specialist in Orthodontics for Children and Adults

How else did you hear about us? (Check all that apply)

DENTAL HISTORY

Do you:

Do you have:

ATTITUDE TOWARD TREATMENT

MEDICAL HISTORY

RESPONSIBLE PARTY INFORMATION

ORTHODONTIC INSURANCE INFORMATION

I understand that where appropriate, credit bureau reports may be obtained.

GET ACQUAINTED QUESTIONNAIRE
ADULT