CALL 1.833.321.STR8 | Camp Hill, PA | Harrisburg, PA | Carlisle, PA

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Adult Patient Information Form

Patient Information
Name*
First Last
Middle Name
Nickname
Date of Birth*
SSN
(enter without dashes) (Note: this field will be encrypted for your personal safety)
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Cell Phone*
Email*

example@example.com
Family Physician
Dentist
Emergency Contact Full Name:*
Emergency Contact Phone:*
Emergency Contact Relationship:*
Which office will you be visiting?*

Employment Information
Employer
Occupation
Work Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Work Phone
Orthodontic Insurance Carrier (if any)

Relative/Spouse Information
Name of Spouse
Date of Birth
MM slash DD slash YYYY
Social Security Number:
Employer
Occupation
Work Phone
Orthodontic Insurance Carrier & ID (if any)

Medical History
Currently in good health?
- Yes
- No
Any major/unusual illnesses?
- Yes
- No
Currently under a physician's care?
- Yes
- No
Currently taking medication?
- Yes
- No
If YES, which medications, if known?
Have you ever taken or are you currently taking any bisphosphonates (ie. Fosamax, Prolia)?
- Yes
- No
Allergies?
- Yes
- No
Drug sensitivity or allergies?
- Yes
- No
If YES, which drugs, if known?
Additional, if any:
Please check if there is a history of
- Clenching Teeth
- Grinding Teeth
- Muscle soreness around head/neck
- Abnormal Headaches
- Jaw/Joint Soreness
- Jaw/Join Clicking
- Jaw/Join Popping
- Ringing in the ear
Please check if you've had any of the following
- Anemia
- Frequent Colds/Flu
- Tuberculosis
- Prolonged Bleeding
- Adenitis
- Endocrine Disease
- Tonsils Removed?
- Adenoids Removed?
- Bone Disorders
- Epilepsy
- Are you in a risk group for AIDS?
- Mouth breathing while awake?
- Mouth breathing while awake?
- Heart Disease
- Blood Disease
- Tonsillitis
- Diabetes
- Hepatitis
- Jaundice
- Rheumatic Fever
- Asthma
- Herpes
- Hemophilia

Dental History
Have you had any severe head or facial injuries?
If YES, When?
Do you have past history of thumb or finger sucking?
Have you previously consulted any Orthodontist?
Have you had any previous orthodontic treatment?
If so, Who was the Doctor or Practice?
Is there any other information which may be helpful?
Why are you seeking orthodontic care?
Whom may we thank for referring you to our practice?
Please note:There is no fee for the initial consultation. There is a fee for diagnostic records if the doctor elects to take them at the initial appointment, or at any other time. Payment is expected at the time of these services. You will be notified of any charges before they occur.
Signature*
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M-TH: 7:30am – 4:00pm

(Carlisle Closed Thursday)

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Mechanicsburg, PA
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Lisburn, PA
Hummelstown, PA
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Camp Hill, PA

1.833.321.STR8
Harrisburg, PA

1.833.321.STR8
Carlisle, PA

1.833.321.STR8

Camp Hill, PA

3412 E Trindle Rd
Camp Hill, PA 17011
Harrisburg, PA

3925 Linglestown Rd
Harrisburg, PA 17110
Carlisle, PA

10 Noble Blvd Suite 2B,
Carlisle, PA 17013