Adult Patient Form

ABOUT YOU Please print this form and bring it with you to your appointment.
Today's Date:	* E-Mail Address:
* Name: *
LAST FIRST MI
I prefer to be called: * Male Female
* Birthdate: * Age: * SS #
* Home Address:
APT/CONDO #
* City: * State: * Zip
* Single Married Divorced Widowed Separated
* Hm #: Pager/Other #:
Wk #: Ext: DL #:
Employer:
Employer's Address:
How long there? Occupation:
* Where & when are the best times to reach you?
Whom may we Thank for referring you?
Other family members seen by us?
* General Dentist:
* Last Visit Date:

SPOUSE INFORMATION

His/Her Name:

Employer:

Wk #: Ext: SS #:

Birthdate: (MM/DD/YYYY)

Person Responsible for Account:

Wk #: Ext: Hm #:

Billing Address:

Relation: SS #:

Employer: DL #:

ORTHODONTIC INSURANCE

Primary

* Orthodontic Coverage Yes No * Dental Coverage: Yes No

* If yes was selected for Orthodontic Coverage and/or Dental Coverage, the following
are required

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #:

Group # (Plan, Local or Policy #):

Insured's Name: Relation:

Insured's Birthdate Insured's SS #:

Insured's Employer:

Secondary

* Orthodontic Coverage Yes No * Dental Coverage: Yes No

* If yes was selected for Orthodontic Coverage and/or Dental Coverage, the following
are required

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #:

Group # (Plan, Local or Policy #):

Insured's Name: Relation:

Insured's Birthdate Insured's SS #:

Insured's Employer:

In the event of an emergency, is there someone who lives near you that we should contact?

* His/Her Name: * Relation:

* Wk #: * Hm #:

MEDICAL HISTORY

* Do you have a personal physician? Yes No

* If you have a personal physician, the physician's name, phone #, and date of
last visit are required

Physician's Name:

Phone #: Date of last visit:

* Your current physical health is: Good Fair Poor

* Are you currently under the care of a physician? Yes No

Please Explain:

* Are you taking any prescription / over-the-counter drugs? Yes No

Please list each one:

* For Women: Are you taking birth control pills? Yes No

* Are you pregnant? Yes No Week #:

* Are you nursing? Yes No

If you have ever had any of the following diseases or
medical problems, please check the corresponding box(s)

Abnormal Bleeding
Anemia
Artificial Bones / Joints / Valves
Asthma / Arthritis
Blood Transfusion
Cancer / Chemotherapy
Congenital Heart Defect
Diabetes
Difficulty Breathing
Drug / Alcohol Abuse
Emphysema
Epilepsy / Seizures/ Fainting
Fever Blisters / Herpes
Glaucoma
Heart Attack / Stroke
Heart Murmer
Heart Surgery / Pacemaker

Hemophilia
Hepatitis
High / Low Blood Pressure
HIV+ / AIDS
Hospitalization for Any Reason
Kidney Problems
Mitral Valve Prolapse
Psychiatric Problems
Radiation Treatment
Rheumatic / Scarlet Fever
Severe / Frequent Headaches
Shingles
Sickle Cell Disease / Traits
Sinus Problems
Tuberculosis (TB)
Ulcers / Colitis
Venereal Disease

Please list any serious medical condition(s) that you have ever had:

If you are allergic to any of the following,
please check the corresponding box(s)

Aspirin
Any Metals/Plastics
Codeine

Dental Anesthetics
Erythromycin
Latex

Penicillin
Tetracycline
Other

Please list any other drugs/medications that you are allergic to:

DENTAL HISTORY

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

* Have you ever had or been evaluated for orthodontic treatment? Yes No

* Have you ever had a serious / difficult problem associated
with any previous dental work? Yes No

* Do you now or have you ever experienced pain /
discomfort in your jaw joint (TMJ/ TMD)? Yes No

* Your current dental health is: Good Fair Poor

* Do you like your smile? Yes No * Gums ever bleed? Yes No

* Have you ever had an injury to your: Mouth Teeth Chin

Do you have a speech problem? Yes No

Speech Problem Description:

* Do you generally breathe through your mouth? Yes No

If yes: While Awake? While Asleep?

* Do you have any missing or extra permanent teeth? Yes No

* Have you ever taken Phen-Fen? (Also known as Redux or Pondimin) Yes No

If yes, when?

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 confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental service that I may need during diagnosis and treatment with my informed consent.
5/24/2006
You must check this box above and enter your name, stating that you understand and agree to the statement above.

This office reserves the right to verify the credit status of potential patients and / or parents of patients prior to extending credit treatmen fees and may, at the discretion of the office, use the service of one or more credit reporting services.
5/24/2006
You must check this box above and enter your name, stating that you understand and agree to the statement above.

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.
5/24/2006
You must check this box above and enter your name, stating that you understand and agree to the statement above.