New Patient Form

NEW PATIENT FORM

11405 W. Palmetto Park Rd.

Boca Raton, FL 33428

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 NameLast Name
Patient's Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone - Home

Area CodePhone Number
Phone - Cell

Area CodePhone 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 NameLast Name
Relation to Patient
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

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

First NameLast Name
Relation to Patient
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
Dental Insurance Information

Skip this section if not applicable
Policy Holder Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SSN (Needed for your complimentary benefits check)
Insurance Company
Insurance Phone Number
Insurance type

Other
Subscriber ID
Group/Policy #
Employer Name
Dental History
General Dentist

First NameLast Name
Dental Practice
Date of last dental exam

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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 NameLast Name
Phone Number

Area CodePhone 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)?
Are you pregnant?
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?
Do you have any drug allergies? If yes, please list:
LATEX ALLERGY?
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
Date Signed

Primary Responsible Party

Secondary Responsible Party (if applicable)

Dental Insurance Information

Dental History

Medical History