Adult Intake
Welcome to the orthodontist
1. About You
Today's date
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Month
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Day
Year
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Your name
*
First Name
MI
Last Name
E-mail
Birthdate
*
-
Month
-
Day
Year
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Gender
*
Male
Female
How old are you?
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Whom we may thank for referring you?
*
General Dentist
*
Last visit date
Marital status
Single
Married
Partnered
Separated
Divorced
Widowed
Other
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2. Spouse Information
Name
First Name
Last Name
Other family members seen by us
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3. Primary orthodontic insurance
Orthodontic coverage
*
Yes
No
Insurance company name
*
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company Phone Number
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Area Code
Phone Number
Group #
Policy #
Policy owner's Name
First Name
Last Name
Relationship to the patient
Policy owner birthdate
-
Month
-
Day
Year
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Policy owner's employer
Employer's address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Orthodontic Insurance
Orthodontic coverage
Yes
No
Insurance company name
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company Phone Number
-
Area Code
Phone Number
Group #
Policy #
Policy owner's Name
First Name
Last Name
Relationship to the patient
Policy owner birthdate
-
Month
-
Day
Year
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Policy owner's employer
Employer's address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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4. What are the main concerns that you would like orthodontics to accomplish?
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Have you ever been prescribed Fosamax or any other bisphosphonate?
*
Yes
No
If yes, when?
Have you ever been evaluated or had orthodontic treatment before?
*
Yes
No
Have there been any injuries to the face, mouth, teeth, or chin?
*
Yes
No
Have adenoid or tonsils removed?
*
Yes
No
Have you ever been informed of any missing teeth or extra permanent teeth?
*
Yes
No
Have you ever had pain / tenderness in his / her jaw joint (TMJ / TMD)?
*
Yes
No
Do you brush teeth daily?
*
Yes
No
Your Physician
Phone Number
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Area Code
Phone Number
Date of last visit
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Month
-
Day
Year
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Are you currently under care of a physician?
*
Yes
No
Please describe your health
*
Good
Fair
Poor
Please list all drugs you are currently taking
*
Please list all drugs / things you are allergic to
*
Allergies to
*
Rows
Yes
No
Latex
Metals/Nickel
Plastics
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5. Have you ever had any of the following medical problem?
*
Rows
Yes
No
Abnormal bleeding
Add/ADHD
Any hospital stays
Any operations
Artificial bones / joints
valves
Asperger syndrome
Asthma
Autism
Cancer
Congenital heart defect
*
Rows
Yes
No
Convulsions/epilepsy
Diabetes
Handicaps/disabilities
Hearing impairment
Heart murmur
Hepatitis
HIV/AIDS
Kidney/liver problems
Lupus
Rheumatic/scarlet fever
Tuberculosis (TB)
Please discuss any medical problems that you have had
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6. Have you ever experienced any of the following?
*
Rows
Yes
No
Clenching/grinding teeth
Lip sucking/biting
Mouth breather
Nail biting
*
Rows
Yes
No
Nursing bottle habits
Speech problems
Thumb/finger sucking
Tongue thrust
Emergency contact
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
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7. I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office any changes in my medical status
I am responsible for payment. Our office is HIPAA compliant and is committed to meeting or exceeding the standards infection control mandated by OSHA, the CDC, and the ADA.
I authorize the dental staff to perform the necessary dental services I may need.
*
This office reserves the right to verify the credit status of potential patients' prior to extending credit for treatment fee and may, at discretion of this office, use the services of one or more credit reporting services.
*
If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits directly to this office. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.
*
Date
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Month
-
Day
Year
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Submit
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