Adult Form

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Patient information
 

How'd you find us?*


 

Who should we thank for referring you?*


 

First name*


 

Last name*


 

Date of birth*


 

Age*


 

Gender


 

Mobile number*


 

Ok with receiving texts?*


 

Email


 

Ok with receiving emails?


 

Occupation


 

Address*


 

City*


 

State*


 

Zip code*


 

Name(s) of family members we currently care for


 

List other family members you would like us to care for


 

What treatments interest you?

 Metal Braces
 Invisalign Express

 Ceramic Braces
 Whitening

 Invisalign
 Other

 

What would you like to improve about your smile?*


 
Dental insurance information
   

Do you have dental insurance?*


​​​​​​

Include your dental insurance information:
 

Name of dental insurance*


 

Insurance phone #


 

Policy owner's name*


 

Policy owner's birth date*


 

Member ID or Social Security #*


 

Relationship to patient*


 

Front of insurance card

 

Back of insurance card

 

Would you like to add a secondary dental insurance?


​​​​​​

Include your secondary dental insurance information:
 

Name of dental insurance*


 

Insurance phone #


 

Policy owner's name*


 

Policy owner's birth date*


 

Member ID or Social Security #*


 

Relationship to patient*


 

Front of insurance card

 

Back of insurance card

 

Medical history
 

Have you been diagnosed or treated for a medical condition?*


​​​​

Please indicate which medical condition(s) from the options below:
 

Aids/HIV positive*
 Yes   No

Autism*
 Yes   No

Anemia*
 Yes   No

Cancer*
 Yes   No

Diabetes*
 Yes   No

Difficulty Breathing*
 Yes   No

Drug/Alcohol Abuse*
 Yes   No

Epilepsy*
 Yes   No

Heart Condition*
 Yes   No

Heart Murmur*
 Yes   No

Hepatitis*
 Yes   No

Lung Disorders*
 Yes   No

Psychiatric Problems*
 Yes   No

Radiation Treatment*
 Yes   No

Sinus Problems*
 Yes   No

Speech/Hearing Problems*
 Yes   No

Tuberculosis*
 Yes   No

Vision Problems*
 Yes   No
 


Explain in detail the medical condition(s) where you have answered with "Yes", else, type "None"*


 

Are you taking any medications (include over-the-counter)?*


 

List the medications that you are currently taking*


 

Do you suffer from any allergies?*


​​​​​​

Are you allergic to any of the below?
 

Anesthetics
 Yes

Aspirin
 Yes

Amoxicillin
 Yes
 

Codeine
 Yes

Cyclosporins
 Yes

Erythromycin
 Yes
 

Latex
 Yes

Nickel
 Yes

Penicillin
 Yes
 

Sulfa Drugs
 Yes

Tetracycline
 Yes

Other
 Yes
 

What other medicines and or materials are you allergic to?*


 
Dental history
  

Last dental visit


 

Current dentist's name


 

Dentist's phone


 

Please answer the following questions:
 
Have had complications following dental treatment?
 Yes   No

Ever injured any teeth?
 Yes   No

Ever injured jaw or face?
 Yes   No
Currently have cavities/toothaches that need treatment?
 Yes   No

Needs to be pre-medication before dental treatment?
 Yes   No

Have had Orthodontic treatment (Braces or Invisalign) before?
 Yes   No
 
Acknowledgement

I have examined the above information and it is true and correct.
 
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