Larchmont Ortho Adult Form

GENERAL INFORMATION

What concerns you about your teeth?

Who suggested that you might need orthodontic treatment?

Why did you select our office?

Have you had any previous orthodontic treatment? Please describe.

Have any other family members been treated In this office? Please name them.

Do you think that any of your work or leisure activities affect your teeth or Jaws? Please explain.

FINANCIAL RESPONSIBILITY

Who is financially responsible for this account?

Address (If different than page 1)

City, State, Zip

Home phone

Cell phone

E-mail address(es)

Social Security #

Employer

DENTAL INSURANCE

Primary policy holder's full name

Birth date

Social Security #

Relationship to patient

Address and phone (If not listed above)

Employer

Address

Insurance company

Group#

ID#

Does this policy have orthodontic benefits?

Yes No Don't know

Secondary policy holder's full name

Birth date

Social Security #

Relationship to patient

Address and phone (If not listed above)

Employer

Address

Insurance company

Group#

ID#

Does this policy have orthodontic benefits?

Yes No Don't know

MEDICAL INSURANCE

Policy holder’s full name

Insurance Company

PATIENT HEALTH INFORMATION

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements, that you take.

Medication

Taken for

Medication

Taken for

Medication

Taken for

Have you ever taken any medications to strengthen your bones? Please describe.

Do you take antibiotic pre-medication before any dental procedures?

Do you or have you ever had a substance abuse problem?

Do you chew or smoke tobacco?

Have you noticed any changes in your face or Jaws?

Any other physical problems?

How often do you brush?

How often do you floss?

Women: Are you pregnant? Yes No

Are you trying to become pregnant? Yes No

FAMILY MEDICAL HISTORY

Have your parents or siblings ever had any of the following health problems? If so, please explain.

Bleeding disorders

Diabetes

Arthritis

Severe allergies

Unusual dental problems

Jaw size Imbalance

Other family medical conditions?

RELEASE AND WAIVER

I authorize release of any Information regarding my orthodontic treatment to my dental and/or medical Insurance company.

Signature

Date

I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.

Signature

Date

MEDICAL HISTORY UPDATES OR CHANGES

Changes

Signature

Date

Dental Staff Signature

Date

Changes

Signature

Date

Dental Staff Signature

Date

Changes

Signature

Date

Dental Staff Signature

Date

Medical Dental History Form
for Adult Patients

CONFIDENTIAL

PATIENT

CLOSEST RELATIVE

DENTIST

PHYSICIAN

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL INSURANCE

MEDICAL HISTORY

DENTAL HISTORY

PATIENT HEALTH INFORMATION

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER

MEDICAL HISTORY UPDATES OR CHANGES

Medical Dental History Formfor Adult Patients

CONFIDENTIAL

PATIENT

CLOSEST RELATIVE

DENTIST

PHYSICIAN

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL INSURANCE

MEDICAL HISTORY

DENTAL HISTORY

PATIENT HEALTH INFORMATION

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER

MEDICAL HISTORY UPDATES OR CHANGES

Medical Dental History Form
for Adult Patients