Adult Patients

PATIENT

Date

Patient's Last name

First name

Middle initial

I prefer to be called

Birth date

Social Security

Middle initial

What are your preferred pronouns?

Home address

City

State

Zip code

Cell phone

Home phone

Work phone

E-mail address

Occupation

Employer

CLOSEST RELATIVE

Spouse or closest relative’s name(s)

Relationship to patient

I prefer to be called

Home phone

Work phone

E-mail address

DENTIST

Patient’s Dentist

Address

City

State

Last seen

Reason

Next appointment

Other dentists/dental specialists now being seen:

Name

City

State

Reason

PHYSICIAN

Patient’s Physician

City

State

Last seen

Reason

Next appointment

Most recent physical exam

Other physicians/health care providers being seen now:

Name

City

State

Reason

Name

City

State

Reason

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 from page 1)

City

State

Zip code

Cell phone

Home phone

E-mail address

Social Security

Employer

DENTAL INSURANCE

Primary policy holder’s full name

Birthdate

Social Security

Relationship to patient

Address and phone (if not listed above)

Employer

Address

Insurance company

Group #

ID #

Does this policy have orthodontic benefits?

YesNoDon't know

SECONDARY INSURANCE

Secondary policy holder’s full name

Birthdate

Social Security

Relationship to patient

Address and phone (if not listed above)

Employer

Address

Insurance company

Group #

ID #

Does this policy have orthodontic benefits?

YesNoDon't know

MEDICAL INSURANCE

Policy holder’s full name

Insurance company

Adult Patients

Medical Dental History Form for Adult Patients

PATIENT

CLOSEST RELATIVE

DENTIST

Other dentists/dental specialists now being seen:

PHYSICIAN

Other physicians/health care providers being seen now:

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

SECONDARY INSURANCE

MEDICAL INSURANCE

MEDICAL HISTORY

Now or in the past, have you had:

Have you had allergies or reactions to any of the following:

DENTAL HISTORY

Now or in the past, have you had:

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