New Patient Form

NEW PATIENT FORM

9250 Glades Road Suite 208

Boca Raton, FL 33434

Phone: 561-756-9227

Fax: 561-756-9215

Email: info@GoldenbergOrthodontics.com
We are excited to see you for your complimentary consultation! By filling this form out in advance, we will be able to address your needs more efficiently.
Name of Patient *

First Name Last Name
Patient's Date of Birth *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone - Home

Area Code Phone Number
Phone - Cell *

Area Code Phone Number
Cell Carrier *
E-mail *
Who may we thank for referring you? How did you hear about our office? *
What would you like to correct about your smile? *
Primary Responsible Party
Name *

First Name Last Name
Relation to Patient *
Date of Birth *

Month Day Year
Date
Address (if different from above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
E-mail
Secondary Responsible Party (if applicable)
Name

First Name Last Name
Relation to Patient
Date of Birth

Month Day Year
Date
Address (if different from above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
E-mail
Dental Insurance Information

Skip this section if not applicable
Policy Holder Name

First Name Last Name
Date of Birth

Month Day Year
Date
SSN (Needed for your complimentary benefits check)
Insurance Company
Insurance Phone Number
Insurance type

PPO HMO Discount Plan I Don't Know
Subscriber ID
Group/Policy #
Employer Name
Dental History
General Dentist *

First Name Last Name
Dental Practice
Date of last dental exam

Month Day Year
Date
Please check the boxes of any that apply *
Any history of injuries to the mouth? If yes, Please explain
Medical History
Physician's Name *

First Name Last Name
Phone Number

Area Code Phone Number
Any recent illness (or) surgeries? If yes, please describe
Are you currently under the care of a physician? If yes, please describe
Have you started your menstrual cycle (this allows us to evaluate the patients future jaw growth status)? *

Yes No n/a
Are you pregnant? *

Yes No n/a
Please check the box if you a have significant medical history consisting of... *
Are you currently taking any medication(s)? If yes, please list:
Have you ever been requested by your physician to pre-medicate before dental appointments? *

Yes No I don't remember
Do you have any drug allergies? If yes, please list:
LATEX ALLERGY? *

Yes No
I understand the information that I have given is correct to the best of my knowledge, that it will be held to the strictest confidence, and it is my responsibility to inform this office of any changes in my medical status. I also authorize the orthodontic staff to perform the necessary orthodontic services I may need.
Signature

Clear
Date Signed

Now create your own Jotform - It's free! Create your own Jotform

Primary Responsible Party

Secondary Responsible Party (if applicable)

Dental Insurance Information

Dental History

Medical History