Adult Form Please bring a copy of your insurance card, if available, to your initial consultation. Adult Form Adult registration form. "*" indicates required fields Patient InformationPatient's Name* First Last Patient's Preferred Pronouns Current Gender Identification Male Female Other Patient's Sex Assigned at Birth Male Female Birthday* MM slash DD slash YYYY Age Street Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Cell Phone*Home PhoneOk to Leave a Message?* Yes No Email Employer's Name* Occupation* Marital Status* SIngle Married Divorced Widowed Significant Other Spouse/Partner's Name First Last Spouse/Partner's Birthday* MM slash DD slash YYYY Address(If different than patient) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Phone*Phone Type* Home Cell Secondary PhonePhone Type Home Cell Work Dental Insurance InformationPlease provide all requested dental insurance information below.Insurance Company Phone NumberGroup Number Member ID Number Policy Holder's Name Relation to Patient Policy Holder's Date of Birth MM slash DD slash YYYY Employer Work Phone NumberGeneral Dentist Last Visit MM slash DD slash YYYY How did you hear about our practice?* Invisalign Website Internet Family/Friend Dentist Other Name of referring party (if applicable) What are the main concerns you would like orthodontics to correct?*Have you ever visited an orthodontist before?* Yes No If yes, when and why? Have your tonsils or adenoids been removed?* Yes No Have you ever experienced jaw joint pain or discomfort (TMJ/TMD)?* Yes No Do you have any missing or extra permanent teeth?* Yes No Have you ever had any of the following injuries (select all that apply)? Teeth Mouth Chin Do you have speech problems?* Yes No If yes, please explain? Do your gums bleed?* Yes No Do you smoke?* Yes No Do you like your smile?* Yes No Do you currently have or ever had any of the following (check all that apply)? Clenching/Grinding Teeth Snoring Mouth Breathing Sleep Apnea Thumb/Finger Sucking Chewing/Eating Problem Are you currently being treated by a physician?* Yes No If yes, for what reason? Physician Last Visit MM slash DD slash YYYY PhoneDo you have any allergies and/or sensitivities to medications or latex??* Yes No If yes, please list them below:Are you currently taking any prescription or over-the-counter medications?* Yes No If yes, please list them below with the dosage:Have you ever taken any of the group of drugs collectively referred to as "bisphosphonates?" These include Fosamax (alendronate), Actonel ( risedronate), Boniva (ibandronate), Skelid (tiludronate), Didronel (etidronate), Aredia (pamidronate), or Zometa (zoledronic acid).* Yes No Have you had any serious illnesses or operations? If yes, please describe:Have you ever had a blood transfusion?* Yes No If yes, please give approximate dates:[Women] Are you pregnant?* Yes No Nursing?* Yes No Taking birth control pills?* Yes No Please check if you have or have ever had any of the following:* ADD/ADHD Asthma Cancer Circulatory Problems Congenital heart Defect Diabetes Eating Disorder Epilepsy/Seizures Headaches Heart Murmur Hemophilia Hepatitis High Blood Pressure HIV/AIDS Kidney Disease Liver Disease Mental Health Issues Mitral Valve Prolapse Radiation Treatment Respiratory Disease Sinus Infections Substance Abuse Tonsilitis Tuberculosis Venereal Disease (STD) Other If Other, please list below:AuthorizationI understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status. I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.Submitted by:* First Last Date* MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged. View the Child Form
