New Patient Form (Bigman Ortho)

New Patient Form
PATIENT INFORMATION
Patient's Name

First NameLast Name
Gender
Birthdate

MonthDayYear
Date
Patient Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Patient's interests
Name/Age of brothers & sisters
Whom may we thank for referring you to our office?
School currently attending
RESPONSIBLE PARTY INFORMATION
Email
example@example.com
Marital Status
Parent/Guardian #1

First NameLast Name
Relationship to Patient
SSN
Birthdate

MonthDayYear
Date
Mailing Address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work/Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Previous Address (if less than 3 yrs)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Occupation
No. Years Employed
Parent/Guardian #2

First NameLast Name
Birthdate

MonthDayYear
Date
Work/Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Employer
Occupation
No. Years Employed
DENTAL INSURANCE INFORMATION

Subscriber #1
Subscriber Name #1
SS# or ID# of Subscriber
Subscriber Date of Birth

MonthDayYear
Date
Employer
Insurance Company
Insurance Phone No.
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Group #
DENTAL INSURANCE INFORMATION

Subscriber #2
Subscriber Name #2
SS# or ID# of Subscriber
Subscriber Date of Birth

MonthDayYear
Date
Employer
Insurance Company
Insurance Phone No.
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Group #
I hereby authorize release of any information to other health care providers, as needed, to insurance companies, and business associates including personal health information as well as administrative data. I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations. I certify that the information on this form is complete and true to the best of my knowledge. I understand that where appropriate, credit bureau reports may be obtained.
MEMBER
Print Name
Signature
Date

MonthDayYear
Date
Updated: Print Name
Print Name
Signature
Date

MonthDayYear
Date
PATIENT'S MEDICAL HISTORY
Primary Physician's Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
City
Are you currently taking any medication?
If yes, please describe.
Are you allergic to any food or medication?
If yes, please describe.
Do you have a history of a major illness or accidents?
If yes, please describe.
Have you had any major operations?
Type a question
Have you ever had your tonsils or adenoids removed?
If yes, please describe.
Have you ever had a concussion?
If yes, please describe.
Are you active in sports? If so, what sports?
If so, what sports?
Are there any medical conditions that we should be aware of?
Do you have any speech problems or concerns?
Have you received/are you receiving speech therapy?
Select any of the medical conditions below that you have had or currently have.
PATIENT'S DENTAL HISTORY
Dentist's Name
Phone
Please enter a valid phone number.Format: (000) 000-0000.
City
Date of Last Visit

MonthDayYear
Date
Has your dentist mentioned any concerns? If yes, please describe.
Are you experiencing any dental pain?
If yes, please describe.
Have you ever experienced any unfavorable reaction to dentistry?
If yes, please describe.
Have you ever lost or chipped any permanent teeth?
If yes, please describe.
Do you have any type of tongue or thumb habit?
If yes, please describe.
Do you breathe mostly through the mouth?
If yes, please describe.
Do you have difficulty staying asleep at night?
If yes, please describe.
Have there been any injuries to your face, mouth or teeth?
If yes, please describe.
Is any part of your mouth sensitive to temperature or pressure?
If yes, please describe.
Do your gums bleed when you brush?
If yes, please describe.
Do you grind or clench your teeth at night?
If yes, please describe.
In the past, have you ever had the following in your jaw or jaw muscles?
Episodes when the jaw would not open or close normally?
If yes, please describe.
Pain or discomfort in the front of the ear?
If yes, please describe.
Have you ever experienced chronic ringing in your ears?
If yes, please describe.
Headaches, neck and/or back pain?
If yes, please write date and details:
If the Patient is under the age of 20, what is the height of their parents?
Mom
Dad
For Female patients only: Are you pregnant?
For Female patients only: To determine growth pattern,has menstruation started?
If so, when?
Signature
IN CASE OF EMERGENCY PLEASE CONTACT:
Name of nearest relative/friend that we should contact in case of an emergency (within a 20 mile radius):
Name
Relationship
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Reviewed by Dr. Bigman:
Date

MonthDayYear
Date
Signature
Should be Empty:

New Patient Form

PATIENT INFORMATION

RESPONSIBLE PARTY INFORMATION

DENTAL INSURANCE INFORMATION

DENTAL INSURANCE INFORMATION

MEMBER

Updated: Print Name

PATIENT'S MEDICAL HISTORY

PATIENT'S DENTAL HISTORY

If the Patient is under the age of 20, what is the height of their parents?

IN CASE OF EMERGENCY PLEASE CONTACT: