New Patient Form Step 1 of 425%Step 1. Basic InformationToday's Date* Date Format: MM slash DD slash YYYY Patient Name* First Name Last Name Gender*Patients GenderMaleFemaleDate of Birth* Date Format: MM slash DD slash YYYY School Attended (if under 18yrs of age)Siblings name #1 (if patient is under 18yrs of age) First Name Last Name Siblings Date of Birth Date Format: MM slash DD slash YYYY Siblings name #2 (if patient is under 18yrs of age) First Name Last Name Siblings Date of Birth Date Format: MM slash DD slash YYYY Siblings name #3 (if patient is under 18yrs of age) First Name Last Name Siblings Date of Birth Date Format: MM slash DD slash YYYY Siblings name #4 (if patient is under 18yrs of age) First Name Last Name Siblings Date of Birth Date Format: MM slash DD slash YYYY School Attended (if under 18yrs of age)Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How Did You Hear About Our Office?*Please SelectDentist Referral (Please list their name below)Family Member (Please list their name below)Staff Member (Please list their name below)Friend (Please list their name below)GoogleFacebookYelpInternet / Other (please list below)Smiles Ortho WebsiteInsurance Company (please list below)Billboard / SignOffice Drive ByValpakEvent / Flyer (please list below)Other (please list below)Otherplease list how you heard about us (friend,internet,etc)Step 2. Responsible Party InfoWho is the Responsible Party for Billing? Myself (if over 18yrs of age) Responsible Party (if under 18yrs of age)Responsible Name #1* First Name Last Name Relationship to Patient*SelfMotherFatherStepmotherStepfatherGrandmotherGrandfatherLegal GuardianOtherGender*Please SelectMaleFemaleDate of Birth* Date Format: MM slash DD slash YYYY Marital Status* Single Married Divorced WidowedSSN*Email* Cell Phone*Cell Phone Carrier*AlltelAmeritechATTBellsouthBoostCellularOneCingularConsumerCorr WirelessCricketEdge WirelessMetro PCSNextelO2OrangePage PlusQwestRogers WirelessSprint PCSTeleflipTelus MobilityTmobilUS CellularVirginVerizonHome PhoneWork PhoneAddress (Click here if address is the same as the patient)Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is there an additional Responsible Party?* Yes NoResponsible Name #2* First Name Last Name Relationship to Patient*SelfMotherFatherStepmotherStepfatherGrandmotherGrandfatherLegal GuardianOtherGender*Please SelectMaleFemaleDate of Birth* Date Format: MM slash DD slash YYYY Marital Status* Single Married Divorced WidowedSSN*Email* Cell Phone*Cell Phone Carrier*AlltelAmeritechATTBellsouthBoostCellularOneCingularConsumerCorr WirelessCricketEdge WirelessMetro PCSNextelO2OrangePage PlusQwestRogers WirelessSprint PCSTeleflipTelus MobilityTmobilUS CellularVirginVerizonHome PhoneWork PhoneAddress (Click here if address is the same as the patient)Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact Name (other than patient/responsible party)* First Name Last Name Relationship to Patient*Phone*Is there any Insurance Coverage to verify?* Yes NoPrimary Insurance InformationSubscriber Name* First Name Last Name Relationship to Patient*SelfSpouseMotherFatherStepmotherStepfatherGrandmotherGrandfatherLegal GuardianOtherDate of Birth* Date Format: MM slash DD slash YYYY Insurance Company*Insurance Phone #*Employer*Group #*Policy ID #SSN #Secondary Insurance InformationSubscriber Name First Name Last Name Relationship to PatientSelfMotherFatherStepmotherStepfatherGrandmotherGrandfatherLegal GuardianOtherDate of Birth Date Format: MM slash DD slash YYYY Insurance CompanyInsurance Phone #EmployerGroup #Policy ID #SSN #Step 3. Medical HistoryMedical History (Check those that apply)* Allergies Asthma (Inhaler-controlled) Cancer Cold Sores Epilepsy/Convulsions Heart Trouble High Blood Pressure Low Blood Pressure Kidney/Liver Disease Migraines Radiation Therapy Respiratory Problems Seizures Stroke Ulcer Anemia Bone Disorder Cardiac Pacemaker Diabetes/Glaucoma Fainting Hepatitis / Jaundice HIV/AIDS Leukemia Pneumonia Removal of Tonsils/Adenoids Rheumatic Fever Sinus Problems Thyroid Disease None OtherAllergies (if any)OtherPhysician NamePast Dental History (Check any current symptoms)* Anxiety with dental treatment Require a pre-medication before dental appointments Feel pain to any teeth Have any sores/lumps in or near your mouth Had a serious head/neck/jaw injury Ongoing joint popping/clicking Ongoing pain in your jaw(s) Frequent difficulty opening/closing your jaw Frequent difficulty chewing Clench/grind your teeth Frequently bite your lips/cheeks Had speech therapy Nail-biting habit Tongue-thrusting habit Mouth-breathing habit Thumb/finger sucking habit None OtherOtherStep 4. Dental HistoryGeneral Dentist Name*Approximate Date of Last Exam/CleaningIs there any outstanding dental work needing to be completed?* Yes No Not sureHas the patient had an orthodontic evaluation in the past? When and with whom? Yes NoWho performed the last orthodontic evaluation?What concerns are you seeking treatment for?* Crowding Extra Spaces Teeth stick out too far TMJ problems Poor Bite Alignment Missing Teeth Extra Teeth None Other (please list below)OtherSignature
