Adult New Patient Forms | Alameda Orthodontics

Medical History

Have the tonsils and/or adenoids been removed? Yes No

If so, at what age?

Frequent colds or ear infections? Yes No

Please describe:

History of major illness? Yes No

Please describe:

Any drug sensitivities? Yes No

Please describe:

Taking any medication now? Yes No

Please list:

Under medical care now? Yes No

Please describe:

Have you been vaccinated and tested for immunity to Hepatitis B (HBV)? Yes No

Date:

Dental History

Have there been any severe injuries to the face? Yes No

Please describe:

Are you aware of any missing permanent teeth? Yes No

Which ones?

Do you clinch or grind your teeth? Yes No

Please describe when:

Do you have pain or clicking upon opening or closing your mouth or jaws? Yes No

Have you had any previous orthodontic treatment? Yes No

When and where?

When did you last visit the dentist?

Comments:

Responsible Party Information

Residence:

Mailing Address if different:

City:

State:

Zip:

Main phone:

Work Phone:

Birthdate:

Relationship to patient:

Employer:

Employer Address:

Spouse/Partner name:

Relationship to patient:

Employer:

Employer Address:

Birthdate:

Main Phone:

Work Phone:

Parent's home address (if not living with patient):

City:

State:

Zip:

Phone (if not living with patient):

Dental Insurance Information

To assist us in determining your financial arrangements, and because your insurance is a contract between you and your insurance company, please call your insurance carrier or benefits officer to verify this information BEFORE your appointment.

Insured's name:

Insured's Soc Sec or ID#:

Group/Local No:

Insurance Company:

Insurance Co. Address:

Insurance Co. Phone:

Insured's relationship to patient:

Ortho Benefits:

No Yes

%:

Lifetime Maximum Amount:

Eligible now: Yes No

Effective Date:

Are orthodontic records covered under general dental? Yes No

Does insurance carrier require additional claim forms after the initial claim form? Yes No

If yes, how often?

Do you have dual coverage? Yes No

If yes, please complete the above information for the second insurance carrier on a separate piece of paper or below.

Authorization

The above information is accurate to the best of my ability.

Signature:

Date:

Adult New Patient Information

Patient Information - Adult

Medical History

Dental History

Responsible Party Information

Dental Insurance Information

Authorization