Leber Ortho Health History Form

New Patient Form

Submit your health history form today!

Take a few minutes to fill out this confidential form and click “submit”. Your information will be sent to our office with secure encryption.
No consultation scheduled yet? No problem - once you submit your form, you can either call us to set up your free new patient exam or our front office will reach out to you soon to set up your appointment. Presione aquí para obtener el formulario en español.

Patient Information

Date:

First Name:

Middle Name:

Last Name:

Patient's Preferred Name:

Sex:

Male Female Non-binary

Age:

Birthdate:

Address:

City:

State:

Zip code:

Cell #:

Home Phone #:

Email Address:

How did you hear about our office?

School/Occupation:

Current Grade:

Sports/Hobbies/Musical Instruments:

Name of other family members previously treated here:

Emergency Contact:

Relation:

Person Responsible For Account

Same as Above?

Yes No

Name:

Relation to patient:

Phone # (if different than above):

Occupation:

Address: (If different then patient’s)

City:

State:

Zip code:

Parent 2 name (if applicable):

Relation to Patient:

Phone # (if different than above):

Occupation:

Address: (If different then patient’s)

City:

State:

Zip code:

Dental Insurance Information

Primary Insurance Information

Policy Holder's Name:

Policy Holder's D.O.B.:

Social Security #:

Insurance Company:

Group No.:

Ins Phone:

Policy Holder's Employer:

Subscriber/Employee ID #:

Do you have dual coverage?

Yes No

Is there a divorce decree in effect?

Yes No

If so, who is listed as primary?

Secondary Insurance Information

Policy Holder's Name:

Policy Holder's D.O.B.:

Social Security #:

Insurance Company:

Group No.:

Ins Phone:

Policy Holder's Employer:

Subscriber/Employee ID #:

New Patient Form

Patient Information

Person Responsible For Account

Dental Insurance Information

Primary Insurance Information

Secondary Insurance Information

What are the main concerns that you would like orthodontics to address?

Has the patient ever had any of the following medical problems?

Does/Has the patient have/had any of the following habits?

Signatures