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 When
