Adult Orthodontic Acquaintance Form
Patient Information
Title:
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Phone:
Birthdate:
Dentist Name:
Email:
(For Appointment Reminders
)
Referred By?
Billing Information
Check if Person Financially Responsible is the same as Patient
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Email:
Phone:
Dental Insurance Information
Insured's Full Name:
Birthdate:
Insured's SSN or ID#:
Patient's Full Name:
Insured's Employer:
Phone:
Dental Insurance Carrier:
Group Number:
Insured's Employer:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Medical History
Have you ever taken a Bisphosphonate for bone loss related issues?
No
Yes
Do you have any history of major illnesses? If so, what for?
No
Yes
Do you require premedication prior to dental visits?
No
Yes
Do you have drug sensitivities or allergic reactions?
No
Yes
If so, please list:
Please list any medications currently being taken by the patient (include non-prescription):
Are you under medical care now, other than routine?
No
Yes
Physician Name:
Physician Phone:
Please select 'Yes' if the patient has been treated for any of the following.
Diabetes?
No
Yes
Arthritis?
No
Yes
Hearth Trouble/Murmur?
No
Yes
AIDS/ARC?
No
Yes
Asthma?
No
Yes
Epilepsy?
No
Yes
Rheumatic fever?
No
Yes
Sleep Apnea?
No
Yes
Prolonged bleeding?
No
Yes
Nervous disorders?
No
Yes
Hepatitis?
No
Yes
Tuberculosis?
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Dental History
Have you suffered any severe injury to the face?
No
Yes
Are you aware of any missing permanent teeth?
No
Yes
Do you clench or grind your teeth?
No
Yes
Do you have pain or clicking upon closing?
No
Yes
Have you had any previous orthodontic treatment?
No
Yes
When did you last visit your dentist?
E-Signature:
Date: