New Patient Information Form

Orthodontic treatment is a team effort. The orthodontist and his staff suggest an orthodontic game plan, put in place the necessary equipment to play the orthodontic game, and coach the players. But frequently the orthodontist and staff can't participate as much as they would like in playing, or even directing the course of the game. The patient and family are the most important members of the orthodontic team!

Who will be responsible on your team for your cooperation in wearing appliances (various kinds of braces and retainers? And for proper cleaning (brushing and flossing) of your teeth and gums?

MotherFatherSelf

Patient Information

Date

NameLast

First

M

Nickname

MaleFemale

AddressStreet

APT. #

City

State

Zip

Birth Date

Age

TelephoneHome

Work

Cell

Place of Employment

SS#

If full time student, school name

Grade

Primary Dentist

Names and ages of siblings

Whom may we thank for referring you to our office?

Family Information

Father (Or Husband)

D.O.B

Last

First

M

Street

City

State

Zip

Home Telephone#

Work Telephone #

Employer

Dental Insurance

Social Security #

Group #

Mother (Or Wife)

D.O.B

Last

First

M

Street

City

State

Zip

Home Telephone #

Work Telephone #

Employer

Dental Insurance

Social Security #

Group #

Person to contact in case of emergency

Ourside of Immediate Family/Household

Name

Address

City/State/Zip

Telephone #

DENTAL HISTORY

MEDICAL HISTORY

Do you now have or have you ever had any of the following? Please check boxes below.

YesNo

Jaw Joint (TMJ) Problems

Have you ever had any other serious illnesses not checked above?

YesNo

Discuss

Do you wish to talk to the dentist privately about any problem?

YesNo

To the best of my knowledge, all the preceding answers are correct. if I have any changes in my health status or if my health status or if my medicines change, I shall inform the dentist and staff at the next appointment without torture.

Patient Signature (Parent or Guardian) X

Date

Reviewed by Doctor

Date

BP

History Review and Significant Findings

New Patient Information Form

Patient Information

Family Information

Father (Or Husband)

Mother (Or Wife)

Person to contact in case of emergency

PERSON RESPONSIBLE FOR ACCOUNT

DENTAL HISTORY

MEDICAL HISTORY

MEDICAL UPDATES

CLINICAL EXAMINATION

TREATMENT PLAN