Adult Patient Information Form

Please describe the orthodontic problem in your own words:

Name

First Last

Prefer to be called

Gender

Male
Female

Address

Street Address City State ZIP Code

Phone

If this is a cellular number, who is the cell phone service provider?

Birthdate

Age

Email

Whom may we thank for referring you to our office?

Who first noticed the problem?

Self
Dentist

What concerns you most about orthodontic treatment? Please check all that apply.

Cost
Length of time
Discomfort
End result
Appearance in braces

Person responsible for account:

Relationship to patient:

Occupation of person responsible:

Employer of person responsible:

Person responsible work phone

Secondary insurance coverage?

Our services are billed to the patient or their responsible party. Your dental insurance is a contract between the insured family member/employee and their insurance company. We will gladly assist you in submitting claims by filling out paperwork, but you are ultimately responsible for fees incurred even if your insurance changes. Please have your insurance card and social security number if you have orthodontic coverage and would like us to inquire about your benefits.

Physician's Name

First Last

Physician's Phone

Please note any current health problems:

Please note any previous health problems:

Please list any medications you are taking:

Please list any medications to which you are allergic:

Have you ever received a blood transfusion?

If so, when and why?

If you have or had any of the following conditions, please check:

If yes, describe or note any additional conditions:

Dentist's Name

First Last

Dentist's Phone

Frequency of dental checkups:

Date of last visit

Is there any unfinished dental work to be completed?

If yes, please explain:

Are you nervous about dental treatment?

If yes, please explain:

Have you had any facial or dental injuries?

If yes, please explain:

Have you had an orthodontic consult before?

If yes, where?

Are you pleased with prior orthodontic treatment?

Please explain:

What changes in your bite or tooth alignment have you noticed?

Please check your chief concern(s):

Chewing function
Aesthetics
Difficulty of cleaning
TMJ
Tooth wear
Long-term stability

Please check if there is a history of:

Ringing in the ears
Mouth breathing
Muscular soreness around the head and neck
Clenching or tooth grinding
Speech problems
Jaw joint soreness, popping, or clicking

Affiliations

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