COOK ORTHODONTICS, P.C. | Adult New Patient Information

Adult New Patient Information

Patient's Name:

Birthday

Sex

Male Female Other

City

State

Zip

Home Phone

Cell Phone

Work Phone

Employment

Occupation

Single

Married

Widowed

Separated

Divorced

Partnered

Spouse’s Name

Occupation

In case of emergency who should be notified?

Phone

Whom may we thank for referring you?

Reason for seeking orthodontic treatment

INSURANCE INFORMATION

Orthodontic Insurance Coverage:

Yes No

Primary Insurance Co.

Subscriber

Social Security Number

Date of Birth

Secondary Insurance Co.

Subscriber

Social Security Number

Date of Birth

I authorize Cook Orthodontics, P.C. to submit insurance claims on my behalf. My signature also serves as my consent for insurance benefits to be assigned to Cook Orthodontics, P.C. I understand that I am financially responsible for all charges whether or not paid by insurance.

Signature

Print Name

Date

Patient’s Dentist

City

Phone

Last check-up/Cleaning

Check “Y” for yes or “N” for no to indicate if you have had any of the following:

Bleeding, swollen, or tender gums

Y N

Burning sensation on tongue

Y N

Chewing/smokeless tobacco

Y N

Cigarette, pipe, or cigar smoking

Y N

Clench the teeth

Y N

Clicking, pain, popping in jaw joint

Y N

Difficulty cleaning the teeth

Y N

Grind the teeth

Y N

Periodontal treatment

Y N

Permanent tooth extractions

Y N

Previous orthodontic treatment

Y N

Prolonged thumb/finger sucking

Y N

TMJ problems and/or treatment

Y N

Wisdom tooth problems

Y N

Dental problems not listed:

Physician’s Name

City

Phone

Are you under the care of a physician at the present time?

Yes No

Describe history of any hospitalizations or operations

List any allergies to metal, latex, or medication

Are you taking or have you ever taken a Bisphosphonate medication such as Fosamax, Actonel, Boniva?

Yes No

List any medications you are currently taking and the reason why

Check “Y” for yes or “N” for no to indicate if you have had any of the following:

AIDS/HIV

Y N

Allergies

Y N

Anemia

Y N

Arthritis/Rheumatism

Y N

Artificial heart valves

Y N

Artificial joints

Y N

Asthma

Y N

Birth defects/ hereditary disorders

Y N

Cancer

Y N

Chemical dependency

Y N

Circulatory problems

Y N

Diabetes or Hypoglycemia

Y N

Emphysema

Y N

Epilepsy

Y N

Eyes, ears, nose, or throat condition

Y N

Heart murmur

Y N

Heart problems

Y N

Hepatitis Type

Y N

High or low blood pressure

Y N

Kidney disorder

Y N

Liver disorder

Y N

Lung/Respiratory disorder

Y N

Mitral valve prolapse

Y N

Psychiatric care

Y N

Rheumatic fever

Y N

Sexually transmitted disease

Y N

Sinus/Breathing problems

Y N

Stomach ulcer or Hyperacidity

Y N

Stroke

Y N

Thyroid disorder

Y N

Tuberculosis

Y N

Are you pregnant?

Y N

Due date:

Are you nursing?

Y N

Are you anticipating becoming pregnant soon?

Y N

Taking birth control pills?

Y N

Have you had any serious illnesses other than those above? If so, explain

I have read and understand the above questions. I will not hold Dr. Cook or any member of his staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status I will so inform this practice.

Signature

Print Name

Date

Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in my medical status. I authorize Cook Orthodontics, P.C. and the dental staff to perform necessary dental/orthodontic services I may need.

Signature

Print Name

Date

Adult New Patient Information

GENERAL INFORMATION

INSURANCE INFORMATION

DENTAL HISTORY

MEDICAL HISTORY