Adult Registration Form "*" indicates required fields Step 1 of 6 - Patient Information 16% Patient InformationAll fields marked with an asterisk (*) are REQUIRED fields.Patient's Name*Gender Male Female Social Security NumberDate of Birth*Driver's LicenseHome Address*City*State*Zipcode*Primary Phone Number*Primary Phone Type* Home Cell Secondary Phone NumberSecondary Phone Type Home Cell Other Email Address* Employer's NameOccupation Spouse/Emergency Contact InformationMarital Status Single Married Divorced Widowed Significant Other Spouse/Partner's NamePhone NumberRelation to YouAddressCityStateZipcodePerson(s) OK to release appointment or medically related information to concerning you.Relation Insurance InformationPrimary InsuranceDo you have insurance?* Yes No Primary Insurance Company*Phone Number*Group Number*Policy Number*Member ID Number*Policy Holder's Name*Relation*Policy Holder's Social Security Number*Policy Holder's Birth Date (mm/dd/yyyy)*Employer*Work Phone Number*Co-pay (if known)*Deductible (if known)*Secondary InsuranceDo you have secondary insurance?* Yes No Secondary Insurance Company*Phone Number*Group Number*Policy Number*Member ID Number*Policy Holder's Name*Relation*Policy Holder's Social Security Number*Policy Holder Birth Date (mm/dd/yyyy)*Employer*Work Phone Number*Co-pay (if known)*Deductible (if known)* Dental HistoryGeneral Dentist NameLast Visit (mm/dd/yyyy)How did you hear about our Practice? Ad Internet Family or Friend Physician Other Name of person referring (if applicable)What are the main concerns you would like orthodontics to accomplish?Have you visited an orthodontist before? Yes No WhenReasonHave your tonsils or adenoids been removed? Yes No Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)? Yes No Do you have any missing or extra permanent teeth? Yes No Have you ever had an injury to (select all that apply): Teeth Mouth Chin Do you have speech problems? Yes No If yes, please explain:Do your gums bleed? Yes No Do you smoke? Yes No Do you like your smile? Yes No Do you currently or have you ever had any of the following habits? Clenching/Grinding Teeth Chewing/Eating Problems Lip Sucking/Biting Mouth Breathing Nail biting Thumb/ Finger Sucking Medical HistoryAre you currently being treated by a physician? Yes No ReasonPhysicianLast VisitPhone NumberDo you have any allergies/sensitivities to medications or latex? Yes No If yes, please list allergies:Are you currently taking any prescription or over-the-counter medications? Yes No If yes, please list (with dosages):Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)? Yes No Have you had any serious illnesses or operations? Yes No If yes, please describe:Have you ever had a blood transfusion? Yes No If yes, give approximate dates:Are you pregnant? (Women) Yes No Nursing? Yes No Taking birth control pills? Yes No Check if you have or have ever had any of the following: Abnormal Bleeding Anemia Arthritis / Rheumatism Artificial Heart Valves Artificial Joints Asthma Back Problems Blood Disease Blood Transfusion Cancer Chemical Dependency Chemotherapy Circulatory Problems Congenital Heart Defect Cortisone Treatments Cough, Persistent Coughing Blood Diabetes Difficulty Breathing Drug / Alcohol Abuse Epilepsy Emphysema Fainting Fever Blisters / Herpes Glaucoma Headaches Heart Attack Heart Murmur Heart Problems Heart Surgery Hemophilia Hepatitis High Blood Pressure High / Low Blood Sugar HIV / AIDS Hospitalized for Any Reason Jaw Pain Kidney Disease Liver Disease Mitral Valve Prolapse Pacemaker Psychiatric Problems Radiation Treatment Respiratory Disease Rheumatic Fever Scarlet Fever Shingles Shortness of Breath Sickle Cell Disease/ Traits Sinus Problems Skin Rash Stroke Swelling of Feet or Ankles Thyroid Problems Tobacco Habit Tonsilitis Tuberculosis Ulcer Venereal Disease AuthorizationI understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.Authorization Agreement* I have read and agree to the above Patient Signature and/or Responsible Party*Today's Date (mm/dd/yyyy)*NameThis field is for validation purposes and should be left unchanged.
