Adult New Patient Information

Adult Registration Form - Ortho
* required field

Patient Information


Gender*











Primary Phone Number*
Secondary Phone Number











SPOUSE/EMERGENCY CONTACT INFORMATION

Marital Status*












INSURANCE INFORMATION

















DENTAL HISTORY




How did you hear about our Practice?*

Have you visited an orthodontist before?*
Do you currently or have you ever had any of the following?

Medical History

Do you have any allergies/sensitivities to latex?*


Have you had any serious illnesses or operations? If yes, describe:
Check if you have or have ever had any of the following:

Sleep / Airway Issues

Do You Have Any Of The Following Sleep or Airway Issues?

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.






Security Measure