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 Information

Patient's Name*
Current Gender Identification
Patient's Sex Assigned at Birth
MM slash DD slash YYYY
Street Address*
Ok to Leave a Message?*
Marital Status*
Spouse/Partner's Name
MM slash DD slash YYYY
Address
(If different than patient)
Phone Type*
Phone Type

Insurance Information

Please provide all requested insurance information below.
MM slash DD slash YYYY
MM slash DD slash YYYY
How did you hear about our practice?*
Have you ever visited an orthodontist before?*
Have your tonsils or adenoids been removed?*
Have you ever experienced jaw joint pain or discomfort (TMJ/TMD)?*
Do you have any missing or extra permanent teeth?*
Have you ever had any of the following injuries (select all that apply)?
Do you have speech problems?*
Do your gums bleed?*
Do you smoke?*
Do you like your smile?*
Do you currently have or ever had any of the following (check all that apply)?
Are you currently being treated by a physician?*
MM slash DD slash YYYY
Do you have any allergies and/or sensitivities to medications or latex??*
Are you currently taking any prescription or over-the-counter medications?*
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).*
Have you ever had a blood transfusion?*
[Women] Are you pregnant?*
Nursing?*
Taking birth control pills?*
Please check if you have or have ever had any of the following:*

Authorization

I 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:*
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.