Welcome to the Orthodontist

Steve Swenson, DDS

Adult New Patient Form
We would like to welcome you and your child to our office. In an effort to provide the best service possible, we ask that you fill out this form as completely as possible. Thank you for your cooperation.
Patient's Name

FirstLast
Nickname (if preferred)
Birthdate

MonthDayYear
Age
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone

Area CodePhone Number
Cell Phone Provider
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Occupation
How Long?
General Dentist:
How did you hear about our office?
Have we treated another member of your family?
If YES, Name
What are the main concerns that you would like orthodontics to accomplish?
Have you visited an orthodontist before?
If YES, for what reason?
Anything you would like to discuss with the doctor in private?
What school does your child attend?
Any siblings? Please list names and ages
Dental Insurance Information (Marital Status)
Primary
Insurance Company Name
Insurance Company Phone #

Area CodePhone Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Group # (Plan, Local or Policy #)
Insured's Name

First NameLast Name
Insured's Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insured's Employer
Insured's Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary
Insurance Company Name
Insurance Company Phone #

Area CodePhone Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Group # (Plan, Local or Policy #)
Insured's Name

First NameLast Name
Insured's Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insured's Employer
Insured's Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental & Medical History
Are you currently under the care of a physician?
If YES, for what reason?
Physician's Name
Phone Number

Area CodePhone Number
History of major illness?
If YES, please describe
Any sensitivities or allergies?
If YES, please list
Currently taking any medications?
If YES, please list (amount & dose)

Has the child been treated for any the following?

Rows	Yes	No
Asthma
Cancer
Heart Condition
Diabetes
Epilepsy<
Arthritis<
Blood Disorder
Nervous Disorder
Celiac Disease
Tuberculosis (TB)
High Blood Pressure

Does you require antibiotics before dental treatment?
If YES, please explain
Have adenoids or tonsils been removed?
Have there been any injuries to your face, mouth, or chin?
Has you ever had pain/tenderness in his/her jaw joint? (TMJ, TMD)?

Does the patient have any of the following habits?

Rows	Yes	No
Grinding Teeth
Speech Problems
Tongue Thrusting
Thumb / Finger Sucking
Chronic Mouth Breathing
Chewing/ Eating Problems

I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidence, and that it is my responsibility to inform this office of any changes in my medical status.

I hereby authorize the release of any information related to the insurance claim. I consent to examination by the doctor and I authorize payment of any insurance benefits to the office.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com

ACKNOWLEDGEMENT OF RECEIPT OF HIPAA POLICIES AND PROCEDURES

*You May Refuse to Sign This Acknowledgement*
I, blanks have received and reviewed a copy of the dental practice's privacy, breach notifications policies and procedures. I understand that I should ask to see the dental's practice's if I have any questions about these policies and procedures.
Signature
Please Print Patient Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
© 2020 American Dental Association
All Rights Reserved
Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.
This form is educational only, does not constitute legal advice, and covers only federal, not state law (August 14, 2002)
Signature
Please Print Patient Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Relationship
Name

First NameLast Name
Relationship
Name

First NameLast Name
Relationship
Name

First NameLast Name
Relationship
Name

First NameLast Name
Relationship
Should be Empty:

Steve Swenson, DDS

Primary

Secondary

Dental & Medical History

ACKNOWLEDGEMENT OF RECEIPT OF HIPAA POLICIES AND PROCEDURES