ADULT PATIENT INFORMATION FORM
TELL US ABOUT YOU:
Last First MI
What is your chief concern or reason for seeking Orthodontic treatment?

Other family members seen by us:

SPOUSE'S INFORMATION:
EMERGENCY CONTACT INFORMATION:
PERSON RESPONSIBLE ACCOUNT:
Fill in section below if you checked Spouse or Other

  CIRCLE ONE:   CIRCLE ONE
Do you currently feel healthy?
Do you still have your wisdom teeth?
Have you ever been evaluated or had orthodontic treatment before?
Have there been any injuries to your face, mouth, teeth or chin?
Have you been informed of any missing or extra permanent teeth?
Do you need to be premedicated before dental work?
Have you experienced problems with previous dental work?
Have adenoids or tonsils been removed?
Have you ever had any pain / tenderness in your jaw joint (TMJ/TMD)?
Do you brush your teeth daily?
Has your jaw ever clicked, popped or locked?
Do you floss your teeth daily?
Have you noticed your teeth shifting or a change in your bite?
Do your gums bleed?
Do you have frequent headaches?
Are you taking fluoride supplements?
Do you play any musical instruments?
Females: Do you take birth control pills?
Are you pregnant?
Are you Allergic
to any of
the following?
Do you now have or have you had any of the following habits? Do you now have or
have you had any of
the following?

Please list any other Allergies that you have:

Please list any other Habits that you have:

Please fill out the insurance section only if you have ORTHODONTIC insurance.

Our office is committed to meeting or exceeding the standards of infection control
mandated by OSHA, the CDC and the ADA.
We reserve the right to verify the credit status prior to extending credit for treatment.
I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in the medical status of the patient named herein. Additionally, I hereby consent to an initial examination of the patient named herein.