leggettorthodontics.com-Adult Patient Information

Hugh V.Leggett, Jr. DDS,MS Brent L.Leggett DDS, MS
Name

First NameLast Name
Age
Birth Date

MonthDayYear
Sex
Patient's Home Phone

Area CodePhone Number
Patient's Cell Phone
Patient's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse Name

First NameLast Name
Spouse Home Phone

Area CodePhone Number
Spouse Cell Phone
Person Responsible for Account

First NameLast Name
Phone Number

Area CodePhone Number
Patient's Occupation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Work phone

Area CodePhone Number
Spouse's Occupation
Employer
Work phone

Area CodePhone Number
Is patient covered by dental insurance
Carrier Name
Primary Insured Name
SS#
DOB

MonthDayYear
Secondary Insured Name
SS#
DOB

MonthDayYear
Who referred you to this office
Patient's General Dentist
Patient's School (If Applicable)
Has any member of your family had orthodonic treatment
Name

First NameLast Name
Orthodontist
Patient's Interests and Hobbies
DENTAL HISTORY
Chief Oral Complaint
When was the last time you had a dental check up
Do you have any of the following ? Indicate by check the box.
If you have Bleeding Gums, How long
Oral habits, i.e.

Other
Unfavorable dental experience
If yes, Explain
Do you use any of the following:
How often do you brush your teeth
How often do you floss your teeth
MEDICAL HISTORY
Physician's Name

First NameLast Name
Are you presently under a Physician's Care?
What medication are you currently taking?
Do you have or have you had any of the following? Indicate by check the box.
Any other condition?
Pregnant? (If yes, please provide delivery date)
* If any change is the above information, please notify our office of change.
Signature
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