Patient Information Form

Adult Registration Form - Ortho

Patient Information

Marital Status:
Phone Type

Spouse / Partner Information

Phone Type:

Insurance Information

Primary Insurance

Secondary Insurance

General Information

Medical History

Check if you have ever had any of the following:
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)?
Have you ever been hospitalized?
Do you wear a Cardiac Pacemaker?
Do You Have Other Disease, Fainting Problem Or Condition That You Think The Doctor Should Know About?
(Women) Are you pregnant?
Taking birth control pills?

Dental History

Have You Ever Been Treated For Periodontal (Gum) Disease?
Do You Have Any Sores, Blisters, Or Swelling On Your Gums, Lips Or Cheeks?
Do You Grind Or Clench Your Teeth?
Have Your Ever Had Popping Or Clicking Near Your Ear When You Chew?
Have You Had Orthodontic Treatment?
Do You, Or Have You Had Any Dental Disease Problems Or Condition That Hasn't Been Mentioned?


I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I attest to the accuracy of the information on this form.

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