Adult New Patient Intake
Patient Information
Name
First Name
Middle Name
Last Name
Nickname
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Area Code
-
Phone Number
Work Phone
Area Code
-
Phone Number
Cell/ Other Phone
Email
example@example.com
Birth Date
Gender
Male
Female
SSN# (U.S.only)
If patient is a minor, parent's /guardian's name
First Name
Last Name
Referred By:
Responsible Party Information
Name
First Name
Last Name
Residence
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long at this address?
Home Phone
Area Code
-
Phone Number
Work Phone
Area Code
-
Phone Number
Cell/ Other Phone
Email
example@example.com
If patient is under 18, please complete this section.
Previous Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SSN# (U.S. only)
Birth date
Relationship to Patient
Employer
Occupation
Number of Years Employed
Spouse's Name
First Name
Last Name
Relationship to Patient
Employer
Occupation
Number of Years Employed
SSN# (U.S. only)
Birth date
Home Phone
Area Code
-
Phone Number
Work Phone
Area Code
-
Phone Number
Cell/ Other Phone
Email
example@example.com
Dental Insurance Information
Primary Insurance Information
Insured's Name
First Name
Last Name
Insured Person's Date of Birth
Insured's SSN# (U.S. only)
Insurance Company
Group Number
Local Number
Insurance Company Address
Phone Number
Area Code
-
Phone Number
Do yo have dual coverage?
Secondary Insurance Information
Insured's Name
First Name
Last Name
Insured's SSN# (U.S. only)
Insured Person's Date of Birth
Insurance Company
Group Number
Local Number
Insurance Company Address
Phone Number
Area Code
-
Phone Number
Emergency Information
Name of the nearest relative not living with you
First Name
Last Name
Phone Number
Area Code
-
Phone Number
Complete Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical History
Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.
Physician Name
First Name
Last Name
Date of Last Visit
Phone Number
Area Code
-
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please check any of the following which apply to you, and add any relevant comments.
Please list any Prescription or over the counter medications you are taking:
Medication Name
Dosage
Reason for Taking?
1
Medication Name
Dosage
Reason for Taking?
2
Medication Name
Dosage
Reason for Taking?
3
Medication Name
Dosage
Reason for Taking?
4
Medication Name
Dosage
Reason for Taking?
5
Medication Name
Dosage
Reason for Taking?
Please list all allergies.
Do yo have a history of any major illness?
Have you had any major operations?
Have you ever been involved in a serious accident?
Please check any of the following that you have had or currently have:
Abnormal bleeding/Hemophilia
Anemia
Arthritis
Asthma or Hay fever
Bone Disorders
Congenical Heart Defect
Diabetes
Dizziness
Epilepsy
Gastrointestinal Disorders
Heart Problems
Heart Murmur
Hepatitis/Liver Problems
Herpes
High Blood Pressure
HIV/Aids
Kidney Problems
Pneumonia
Neurvous Disorders
Prolonged Bleeding
Radiation/Chemotherapy
Rheumatic Fever
Tuberculosis
Tumor or Cancer
Are there any medical conditions we have not discussed that you feel we should be aware of?
Do you use tobacco?
Yes
No
For Women: Are you pregnant?
Yes
No
Dental History
Dentist Name
First Name
Last Name
Last date of visit:
What concern you most about your teeth?
Please check any of the following which apply to you and add any relevant comment:
Yes
No
Please add any relevant Comment?
Are you presently in any dental pain?
Yes
No
Please add any relevant Comment?
Have you ever experienced any unfavorable reaction to dentist?
Yes
No
Please add any relevant Comment?
Have you ever lost or chipped any teeth?
Yes
No
Please add any relevant Comment?
Have there been any injuries to face, mouth or teeth?
Yes
No
Please add any relevant Comment?
Is any part of your mouth sensitive to temperature or pressure?
Yes
No
Please add any relevant Comment?
Do your gums bleed when you brush?
Yes
No
Please add any relevant Comment?
Do you have any type of thumb or tongue habit?
Yes
No
Please add any relevant Comment?
Are you a mouth breather?
Yes
No
Please add any relevant Comment?
Have you ever seen an orthodontist?
Yes
No
Please add any relevant Comment?
If yes, who?
When?
What is our attitude toward receiving orthodontic treatment?
How did they feel about the result?
Yes
No
Please add any relevant Comment?
Has anyone in your family received orthodontic treatment?
Yes
No
Please add any relevant Comment?
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
Yes
No
Please add any relevant Comment?
Are you aware of your jaws clicking or popping?
Yes
No
Please add any relevant Comment?
Are you aware of clenching your your teeth during the day?
Yes
No
Please add any relevant Comment?
Have you ever been told that you grind your teeth?
Yes
No
Please add any relevant Comment?
Do you have 'tension' headaches?
Yes
No
Please add any relevant Comment?
Have you ever experienced chronic ringing in your ears?
Yes
No
Please add any relevant Comment?
Do you have any extra or missing teeth?
Yes
No
Please add any relevant Comment?
Are you happy with the way your smile looks? If not what would you change?
Yes
No
Please add any relevant Comment?
Over office is HIPPA compliant and is committed to meeeting or exceeding the standards of infection control mandated by OSHA, the CDC , and the ADA. I authorize the dental staff to perform the necessary orthodontic services my child or my self may need.
I agree to terms & conditions.
Signature