Adult New Patient Form

suwaneeorthodontics.com - Adult Registration Form

Patient Information

*Gender:
 
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*Phone Type
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Spouse / Partner Information

Marital Status:
 
 
Phone Type:
Phone Type:

Emergency Contact Information

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Insurance Information

Primary Insurance

 

Secondary Insurance

 

Dental History

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*How did you hear about our practice?
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Have you visited an orthodontist before?
*Have your tonsils or adenoids been removed?
*Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
*Do you have any missing or extra permanent teeth?
*Have you ever had an injury to (select all that apply):
*Do you have speech problems?
*Do your gums bleed?
*Do you smoke?
*Do you like your smile?
*Do you currently or have you ever had any of the following habits (check all that apply):

Medical History

*Are you currently being treated by a physician?
*Do you have any allergies/sensitivities to medications or latex?
*Are you currently taking any prescription or over-the-counter medications?
*Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
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*Have you ever had a blood transfusion?
*(Women) Are you pregnant?
Nursing?
Taking birth control pills?
Check if you have ever had any of the following:

Authorization

I 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.



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