Adult New Patient Registration Form Please fill out the form below or print, fill out and bring into our office on your first visit: Patient Name(Required) Sex(Required) Birth Date(Required) MM slash DD slash YYYY Preferred Name Address(Required) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone(Required)Cell Phone(Required)Work PhoneWith which phone number do you prefer to be contacted?(Required)HomeCellWorkDo you have orthodontic insurance?(Required) Yes No Company(Required) Policy Holder Name(Required) DOB(Required) MM slash DD slash YYYY Policy ID #(Required) Who is your regular dentist(Required) Did they refer you here?(Required) Yes No Date of Last Dental Exam(Required) MM slash DD slash YYYY Whom may we thank for referring you to our office?(Required) Why are you are seeking orthodontic treatment?(Required) Have you been or are you currently treated for any medical/psychological issues? (please list)(Required)Are you taking any medications? (please list)(Required)Have you had any injuries or operations involving the head, neck, or teeth? Please explain(Required)Are you allergic to anything (please list)(Required)Do you have a sensitivity to latex gloves?(Required) Yes No Have you ever had pain/clicking/tenderness of the jaw joint (TMD/TMJ)(Required) Yes No Have you been informed of any missing or extra permanent teeth?(Required) Yes No Do you have a have a history of(Required) Clenching/grinding teeth Thumb/finger sucking Lip sucking/biting Tongue thrust None of the above It is important that the above information is correct and complete. It will be held in the strictest of confidence and used only for in-office treatment and paperwork. Your permission will be required to share given information with any other party.