Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Social Security # (needed to verify insurance benefit):

Please list the names of any friends or family currently in the practice:
Whom may we thank for referring you to our practice?

Financial Party Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Email:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Social Security # (needed to verify insurance benefit):
Do you have dental insurance ?
If so, please name the Insurance Company:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Insurance Plan Address (refer to member card):
Insurance Company Phone (refer to member card):
Subscriber ID:
Subscriber Birthdate:

Dental History

Dentist Name:
Check-up Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
If so, when?
What is the patients main orthodontic concern?

Medical History

Any current medical conditions or allergies (latex, etc.)? Are you currently taking any medication? List below:
RELEASE AND WAIVER
Your answers are for office records only and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. Periodic updates will be requested throughout treatment. I authorize release of information regarding my child’s orthodontic treatment to my dental and/or medical insurance company. I hereby give New England Orthodontic Specialists my permission to communicate with other healthcare professionals regarding treatment recommended.
I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her office team 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 child’s medical/dental health or personal information.
New England Orthodontic Specialists P.C. has taken special precautions to provide secure transmission of your personal information on its website. Here is a link to our Notice of Privacy Practices. I acknowledge that I have given access to the Notice of Privacy Practices and accept them.
Patient/Guardian Signature:
Date: