Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Identifying Gender:
Address:
City:
State:
Zip:

How did you hear about us? Check all that apply.
Whom may we thank for referring you to our practice?

Are any of your friends and/or family currently in treatment with Adirondack Orthodontics? If yes, please list below.
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:

Responsible Party Information

Parent/Guardian 1
First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Phone 1:
Phone 2:
Address:
City:
State:
Zip:

Parent/Guardian 2
First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Phone 1:
Phone 2:
Address:
City:
State:
Zip:

Emergency Contact Information

Emergency Contact 1
Name:
Address:
Relationship to Patient:
Phone:
Emergency Contact 2
Name:
Address:
Relationship to Patient:
Phone:

Dental History

Dentist Name:
Checkup Frequency:
Last Dental Visit:
Dental Hygiene: How frequently do you...
Brush?
Floss?
Fluoride Treatment?
*
Have you ever had a consultation/received orthodontic treatment? If yes, please explain for what and when.
Does the Patient need to premedicate prior to dental visit?
Have wisdom teeth been removed?
*
Are you currently taking any medications? If yes, please indicate each medication.

Please check all/any conditions that apply to you:
If you answered yes to any of the items listed above, please explain each selection. This provides our clinicians all the information needed to provide you the best treatment and care possible.
Do you have or are you experiencing any other dental conditions that were not listed above?

Please check all/any conditions that apply to you:
If you answered yes to any of the items listed above, please explain each selection. This provides our clinicians all the information needed to provide you the best treatment and care possible.

Medical Questionnaire

*
Is the patient under care of a physician? If yes, physician's name:
*
Any changes in the patient's general health within the last year?
*
Has the patient had a serious illness or hospitalization in the past 5 years?
*
Does the patient have an intellectual, cognitive, or developmental disability?
*
Is there anything we can do as a practice to ensure the patient has a positive experience?
*
Is the patient currently taking blood thinners?

Medical History

Allergies/Sensitivities
Please list any other drug allergies or sensitivities that the patient may have:
Please check all/any conditions that apply to you:
If you answered yes to any of the items listed above, please explain each selection. This provides our clinicians all the information needed to provide you the best treatment and care possible.
Do you have or are you experiencing any other medical conditions that were not listed above?

Patient Motivation For Orthodontic Treatment

What would you like to change most in the appearance of your teeth?
How would you change your facial appearance?
Where would you like to reduce pain or discomfort?

Dental Insurance Information

Primary Dental Insurance
Policy Holder's Name:
Relationship to Patient:
Insurance Company:
Subscriber ID:
Group Number:

Secondary Dental Insurance
Policy Holder's Name:
Relationship to Patient:
Insurance Company:
Subscriber ID:
Group Number:
Name:
Relationship to Patient: