New 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)

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 treat 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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Adult Patient Information Form