Adult Patient Form

Adult Patient Form
Patient’s Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age
Patient’s Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Our office uses an automated system for confirming all appointments. This system gives you the option for calling, email and text messages. What is the best telephone # and Email to use?
Phone Number*
Please enter a valid phone number.
Phone Type?

HomeCell
Email*
example@example.com
How did you hear about our office?
Are there other family members that have ever seen in our office?
Spouse Information
Name
Date of Birth

MonthDayYear
Date
SSN
Email
example@example.com
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Employer
Work Phone
Please enter a valid phone number.
Medical History
Dentist*
Last Cleaning Date

MonthDayYear
Date
Physician*
Please check all that apply:*

AsthmaJaw LockingMitro-Valve ProlapseFacial Tooth InjuryEpilepsyLiver DiseaseProphylactic AntibioticsBlood PressurePregnancyHeart DiseaseJaw/Joint NoisePrevious TMJ TherapyArthritisMissing TeethChewing ProblemsContact LensesHepatitisThumb HabitsGrinding of TeethEmotional ProblemsHIV/AIDSRheumatic FeverPrevious OrthodonticsGum DiseaseFrequent HeadachesDiabeticPeriodic MRI/CT Scans Osteoporosis(Fosamax/Evista)Diagnosed SyndromesAllergies (latex/metals)Drug AllergiesNone
Please explain in detail any health issues and list all medications currently taken (including non-prescription drugs):
Insurance Information
Do you have primary dental insurance?*

YesNo
Policy Holder
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
SSN
DENTAL Insurance Carrier
Insurance Phone
Please enter a valid phone number.
DENTAL Claim Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Member ID #
Group #
Employer
Employer Phone
Please enter a valid phone number.
Do you have secondary dental insurance?

YesNo
Policy Holder
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
SSN
DENTAL Insurance Carrier
Insurance Phone
Please enter a valid phone number.
DENTAL Claim Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Member ID #
Group #
Employer
Employer Phone
Please enter a valid phone number.
Insurance: Our office files insurance as a courtesy for our patients. We cannot file your insurance without a copy of your insurance card. If you do not have a copy of your card, please contact your Human Resources Department for the following information: Policy holder’s name as written on the card, name & address of the insurance company, phone number of the insurance company, Member ID# & the Group ID #.
Signature

By signing below, I acknowledge the receipt of a copy of the Notice of Privacy Practices of Innovative Orthodontics, Donihue Waters, DDS, MDS.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Adult Patient Form

Spouse Information

Medical History

Insurance Information

Signature