Adult Patient Form

Adult Patient Form
Patient Name

First NameLast Name
Gender
Social Security Number
Birth Date

MonthDayYear
Date
Age
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type
OK to leave message?
Employer's Name
Occupation
Spouse / Partner Information
Name

First NameLast Name
Marital Status
Social Security Number
Birth Date

MonthDayYear
Date
Address (if different than patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type
Secondary Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type
Dental Insurance Information
Do you have primary dental insurance?
Primary Dental Insurance Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Group Number
Policy Number
Member ID Number
Policy Holder's Name
Relation to Patient
Policy Holder's SSN
Policy Holder's Date of Birth

MonthDayYear
Date
Employer
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you have secondary dental insurance?
Secondary Dental Insurance Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Group Number
Policy Number
Member ID Number
Policy Holder's Name
Relation to Patient
Policy Holder's SSN
Policy Holder's Date of Birth

MonthDayYear
Date
Employer
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Dental History
General Dentist
Last Visit

MonthDayYear
Date
How did you hear about our practice?

Other
What are the main concerns you would like orthodontics to correct?
Have you visited an orthodontist before?
If so, explain:
Medical History
Are you currently being treated by a physician?
If yes, reason:
Do you have any allergies/sensitivities to medications or latex?
If yes, please list:
(Women) Are you pregnant?
Authorization
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.
Submitted by:
Signature:
Date

MonthDayYear
Date
Should be Empty:

Adult Patient Form

Spouse / Partner Information

Dental Insurance Information

Dental History

Medical History

Authorization