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 State ZIP Code

Home Phone(Required)

Cell Phone(Required)

Work Phone

With which phone number do you prefer to be contacted?(Required)

Do you have orthodontic insurance?(Required)

Yes

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

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

Have you ever had pain/clicking/tenderness of the jaw joint (TMD/TMJ)(Required)

Yes

Have you been informed of any missing or extra permanent teeth?(Required)

Yes

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.