Adult Patient Form

Experienced, friendly and dedicated dental health professionals

Preferred Name:

Male Female Non-binary

Social Security Number: Birth Date:
Home Address: City: State: Zip:

Primary Phone: home cell work Ok to leave message? Yes No </fieldset>

Secondary Phone: home cell work other Ok to leave message? Yes No

E-mail: Employer's Name: Occupation:
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Marital Status Single Married Divorced Widowed Significant Other / Partner

Spouse/Partner's Name:
Emergency Contact Name: Phone Number: Relation: Address: City: State: Zip:

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

Primary Dental Insurance Company: Phone Number: Group/Policy Number: Member ID#: Member/Subscriber Name: Relation: Policy Holder's Social Security Number: Policy Holder's Date of Birth:
Employer: Phone Number:

Secondary Dental Insurance Company: Phone Number: Group/Policy Number: Member ID#: Policy Holder's Name: Relation: Policy Holder's Social Security Number: Policy Holder's Date of Birth:
Employer: Phone Number:

General Dentist: Last Visit:

How did you hear about our Practice? Ad Internet Family/Friend Physician Other
Name of person referring (if applicable) :

Have you visited an orthodontist before? Yes No
When: Reason:

Have your tonsils or adenoids been removed? Yes No

Have you ever experienced jaw joint pain/ discomfort (TMJ/TMD)? Yes No

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

Have you ever had an injury to (select all that apply): Teeth Mouth Chin

Do you have speech problems? Yes No
If so, explain:

Do your gums bleed? Yes No

Do you smoke? Yes No

Do you like your smile? Yes No

Do you currently or have you ever had any of the following habits (check all that apply) Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail Biting
Thumb/Finger Sucking
Chewing/Eating Problem

Are you currently being treated by a physician? Yes No
Reason: Physician: Last Visit: Phone:

Do you have any allergies/sensitivities to medications, or latex, or nickel? Yes No
If yes, please list:

Are you currently taking any prescription or over-the-counter medications? Yes No
Please list, with dosage:

Are you pregnant Yes No NA

Are you nursing Yes No NA

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.

Submitted by: Date:

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