New Patient Form

Submit your health history form online to your orthodontist today.

Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form and click "submit". Your information will be sent to our office with secure encryption. We will have your information when you arrive for your first appointment.

Home Phone*

Birthdate*

Marital Status*

Sex*

If patient is a minor, parent's / guardian's name

If patient is a minor, name and ages of siblings

Whom may we thank for referring you to our office?

Sports/Hobbies/Musical Instruments

School/Occupation

Current Grade

Nickname

Person Responsible For Account

Same as Above?* Yes No

Have you been at this address longer than 3 years?* Yes No

Relationship to Patient*

Work Phone

Cell Phone

Social Security #

Employer

Occupation

No. of years employed

Is there an additional responsible party for this account?* Yes No

Dental Insurance Information

Insured's Name

Insured's Birthdate

Social Security #

Insurance Company

Phone

Group No.

Insurance Co. Address

Insured's Employer

Subscriber/Employee ID #

Do you have dual coverage?* Yes No

Emergency Information

Name of nearest relative not living with you*

Relationship*

Cell or Phone*

Complete Address*

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

Please describe concerns*

Has the patient ever been evaluated for or had orthodontic treatment before?* Yes No

Have there been any injuries to the face, mouth, teeth or chin?* Yes No

How does the patient feel about wearing orthodontic appliances?

Have adenoids or tonsils been removed?* Yes No

Has the patient been informed of any missing or extra permanent teeth?* Yes No

Has the patient ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?* Yes No

Does the patient brush his/her teeth daily?* Yes No

Floss his/her teeth daily? Yes No

Patient's Dentist*

Phone

Date of Last Visit

Patient's Physician*

Phone

Is the patient currently under the care of a physician?* Yes No

If patient is a minor, has puberty begun?* Yes No

Please describe the patient's current physical health* Good Fair Poor

Do you take or have you taken an osteoporosis medication?* Yes No

Please list all drugs that the patient is currently taking

Please list all allergies (drugs, foods, other)

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

Abnormal Bleeding* Yes No

ADD/ADHD* Yes No

Sleep Apnea* Yes No

Allergy to Latex/Metals* Yes No

Allergy to Plastic* Yes No

Any Hospital Stays* Yes No

Any Operations* Yes No

Asthma* Yes No

Cancer* Yes No

Congenital Heart Defect* Yes No

Convulsions/Epilepsy* Yes No

Diabetes* Yes No

Handicaps/Disabilities* Yes No

Hearing Impairment* Yes No

Heart Murmur* Yes No

Hemophilia* Yes No

Hepatitis* Yes No

HIV+/AIDS* Yes No

Kidney/Liver Problems* Yes No

Psychological Counseling* Yes No

Rheumatic/Scarlet Fever* Yes No

Tuberculosis (TB)* Yes No

Please discuss any medical problems that the patient has had

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

Chew/Smoke Tobacco* Yes No

Clenching/Grinding Teeth* Yes No

Lip Sucking/Biting* Yes No

Mouth Breather* Yes No

Nail Biting* Yes No

Nursing Bottle Habits* Yes No

Speech Problems* Yes No

Thumb/Finger Sucking* Yes No

Tongue Thrust* Yes No

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in the patient's medical status. I authorize the dental staff to perform the necessary dental services I/my child may need.

This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use services of one or more credit reporting agencies.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.

I understand that at the time of my office visit, my physical signature will be required to confirm the acknowledgements above.

Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

Please check your form to make sure it is complete and press the submit button when you are done. You will see a confirmation page when your form has been successfully submitted. Thank you!

New Patient Form – michaelkierlorthodontics.com

Patient Information

Person Responsible For Account

Dental Insurance Information

Emergency 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