Yardley Ortho New Patient Adult Form

Marital Status

Single

Married

Separated

Divorced

Widowed

Home address

City, State, Zip code

Home phone

Cell phone

Work phone

Occupation

Employer

Closest Relative

Spouse or closest relatives name(s)

Address (if dfferent than patient address)

Home phone (if different)

Cell phone

Work phone

Dentist

Patient's Dentist

Address, City, State

Last seen

Reason

Next appointment

Physician

Patient's Physician

City, State

Last seen

Reason

Next appointment

Most recent physical exam

General Information

What concerns you about your teeth?

Who suggested that you might need orthodontic treatment?

Why did you select our office?

Have you had any previous orthodontic treatment? Please describe.

Have any other family members been treated in this office? Please name them.

Do you think that any of your work or leisure activities affect your teeth or jaws? Please explain.

Financial Responsibility

Who is financially responsible for this account?

Address (if different than page 1)

City, State, Zip

Home phone

Cell phone

Email address(es)

Social Security #

Employer

Dental Insurance

Primary policy holder's full name

Birth date

Social Security #

Relationship to patient

Address and phone (if not listed above)

Insurance company

Group #

ID #

Does this policy have orthodontic benefits?

Yes

Don't Know

Secondary policy holder's full name

Birth date

Social Security #

Relationship to patient

Address and phone (if not listed above)

Insurance company

Group #

ID #

Does this policy have orthodontic benefits?

Yes

Don't Know

Medical Insurance

Policy holder's full name

Your answers are for office records only and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.
For the following questions, please mark yes, no, or don't know/understand (dk/u)

Patient Health Information

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements, that you take.

Medication

Taken for

Medication

Taken for

Medication

Taken for

Have you ever taken any medications to strengthen your bones? Please describe.

Do you or have you ever had a substance abuse problem?

Do you chew or smoke tobacco?

Have you noticed any changes in your face or jaws?

Any other physical problems?

How often do you brush?

How often do you floss?

Family Medical History

Have your parents or siblings ever had any of the following health problems? If so, please explain.

Bleeding disorders

Diabetes

Arthritis

Severe allergies

Unusual dental problems

Jaw size imbalance

Other family medical conditions?

Release and Waiver

I authorize the release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.

I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.

Signature