New Patient Form

RESPONSIBLE PARTY INFORMATION

Patient's Name (last, first, middle, Suffix/Title)

Address (Street, City, Zip)

Date of Birth

Gender Identity

SSN

Home Phone

Mobile Phone

Work Phone

If Patient is a minor, give parent's or guardian's name

Whom may we thank for referring you to our office?

Name of General Dentist or Pediatric Dentist

Hobbies/Interests

Names of other siblings?

DENTAL INSURANCE INFORMATION

Policy holder's Name

Date of Birth

SSN

Name of Employer

Policy Holder Address

Does your job offer a “Flexible spending” account?

What month does it renew?

Insurance Company

Insurance Member ID #

Group No.

Insurance Co. Address

Phone No

Do you have dual coverage?

If yes complete the following below:

Policy holder’s Name

Date of Birth

Policy holder’s Social Security #

Insurance Company

Group No.

Employer

Insurance Co. Address

Phone No

MEDICAL HISTORY OF NEW PATIENT

Patient's Name (last, first, middle, Suffix/Title)

Physician

Date of Last Visit

Address (Street, City, Zip)

Phone

Are you taking any medication?

If Yes, what medication

Are you allergic to any medication/latex/or nickel?

If Yes, please detail

Do you have a history of major illness?

If Yes, please detail

Have you had any major operations?

If Yes, Please indicate

Have you ever been involved in a serious accident?

Details

Are there any medical conditions we have not discussed that you feel we should be aware of?

DENTAL HISTORY OF NEW PATIENT

Dentist

Date of Last Visit

What concerns you most about your teeth?

Are you presently in any dental pain?

Please Indicate

Have you ever seen an orthodontist? If yes, who and when?

Please Indicate

Would you object to wearing orthodontic appliances (braces)? should they be indicated?

Please Indicate

Has anyone in your family received orthodontic treatment?

Please Indicate

Do your teeth or jaws ever feel uncomfortable when you awake in the morning?

Please Indicate

Are you aware of your jaw clicking or popping?

Please Indicate

Are you aware of clenching your teeth during the day?

Please Indicate

Have you ever been told that you grind your teeth?

Please Indicate

Do you have tension headaches?

Please Indicate

Are you aware that some appointments will be during school or work hours?

Please Indicate

For FEMALE Patients Only:

Are you pregnant?

BENEFITS

Benefits of Orthodontics: Esthetics, Beauty, Health, Function, Confidence, and Success. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the function of the teeth, in the dental and medical health of the patient, and in the overall self-esteem and future success of the patient.

I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Gibson to perform a complete orthodontic evaluation.

Signature (Type your Name here again.)

Date: