Adult New Patient Form

Adult Registration Form - Ortho
* required field

Patient Information










Spouse / Partner Information

Marital Status






Person(s) OK to release appointment or medically related information to concerning you:

Insurance Information

Dental And Medical History

Do you smoke?

Do you floss?

Oral habits can effect the position of the teeth and could have adversely effected the growth and development of the face
Do you have any of these habits?

Are you currently being treated by a physician or taking any medications? If yes, please list below:

Have you taken any biophosomates such as Fosamax in the last fifteen years?

Have you ever had rheumatic fever or other heart problems? If yes, please list.

Have you had previous medical problems which I should know about? if so, elaborate

Are you currently taking any over-the-counter medications for seasonal allergies? If so, what type and how many months per year?

Have you ever had any excessive bleeding requiring special treatment? If so, elaborate

Do you clinch or grind your teeth at night?

Does your jaw lock, click or pop during opening, closing or chewing?

Is there any pain associated with this problem?

Have you ever had an injury to (select all that apply):
How often do you breath through your mouth?

Women Only
Are you pregnant or planning to have a child in the near future? If so, when is your due date?

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.



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