New Patient Form
PATIENT INFORMATION
First Name:
Middle Name:
Last Name:
Nickname:
Age:
Date of Birth:
Sex:
Male
Female
Home Address:
Cty / State / zip
Cell:
Home:
Email:
School:
Grade:
Hobbies/Sports:
Employer:
Occupation:
How Long?
GENERAL INFORMATION
How did you hear of Heidi Harman Orthodontics?:
Has the patient had prior orthodontic treatment or exam?:
Where/When?:
General Dentist:
Phone:
Last Visit:
Children/Siblings (Ages):
RESPONSIBLE PARTY INFORMATION
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Separated
Relationship to Patient
Relationship to Patient:
Name:
Sex:
Male
Female
Home Address:
Cty / State / zip
SSN:
Birth Date:
Cell:
Home:
Work:
Email:
Employer:
Occupation:
If you have orthodontic insurance coverage for the patient:
Yes
No
If Yes, then please answer below questions.
Insurance Company Name:
Insurance Phone:
ID#:
Group#:
Relationship to Patient 2
Relationship to Patient:
Name:
Sex:
Male
Female
Home Address:
Cty / State / zip
SSN:
Birth Date:
Cell:
Home:
Work:
Email:
Employer:
Occupation:
If you have orthodontic insurance coverage for the patient:
Yes
No
If Yes, then please answer below questions.
Insurance Company Name:
Insurance Phone:
ID#:
Group#:
MEDICAL HISTORY
History of the following: (Please check all that apply)
Blood Disorder
High Blood Pressure
Nervous Disorder
ADD/ADHD
Arthritis
Epilepsy
AIDS
Asthma
Tuberculosis
Congenital Heart Defect
Joint Replacements
Heart Conditions
Cancer
Diabetes
Bone Density
Hepatitis
HIV
Kidney
Covid-19
History of major illness, please explain:
Is the patient allergic to
LATEX
NICKEL/METALS
PLASTIC
Other Sensitivities / Allergies:
Current Medications:
Does the patient require antibiotics before dental treatment?
Yes
No
Puberty?
Yes
No
Has menstruation started?
Yes
No
DENTAL HISTORY
History of the following: (Please check all that apply)
Difficulty Chewing/Eating
Pacifier (infant)
Tongue Thrust
Clenching/Griding
Finger/Thumb Habit
Sleep Apnea
Snoring
Nail Biting
Ear Pain/Infection
Lip Sucking/Biting/Cheek Biting
Soda/Juice Overconsumption
TMJ: Jaw Popping/Locking
Mouth Breathing
Mouth Guard Usage
Speech
Headaches
Cranofacial/Cervical Pain
Please explain:
Adenoids or tonsils removed?
Yes
No
Missing or extra permanent teeth?
Yes
No
Injuries to the face, mouth or jaw?
Yes
No
Difficulty breathing through nose?
Yes
No
Does the patient brush their teeth daily?
Yes
No
Floss?
Yes
No
Signature
Date: