Adult New Patient Form
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Adult Patient Information


Gender:


Primary Phone: *

Secondary Phone:




Do you know a patient currently in our practice?

Who noticed the orthodontic problem?


What concerns you most about orthodontic treatment?










Family and Account Information











Dental/Orthodontic Insurance Information







Medical History



Have you experienced any health problems?
Any major change in your health recently?
Are you currently under a physician's care?
Are you currently taking any medications?
Are you allergic to any medications?
Have you received a blood transfusion?
Have your tonsils or adenoids been removed?
Have you been in a risk group for AIDS?
Please check if you have had any of the following conditions:
Comments:

Dental History






Frequency of dental checkups:
Is there any unfinished care to be completed with your dentist?
Are you frightened about dental treatment?
Have you had an unpleasant experience in a dental office?
Have you had any face or dental injuries?
Do you play any musical instruments?
Have you consulted an orthodontist previously?
Have teeth (either primary or permanent) been removed?
Have you had any previous orthodontic treatment?
Are you satisfied with prior treatment?

Have you noticed any changes in your bite or dental alignment recently?

What are the chief concerns you have related to the position of your teeth or bite?
What concerns has your dentist(s) expressed concerning your bite or dental alignment?




Please check if there is a history of:









Is there any other information that may be helpful?

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. I also acknowledge that I have received or have been give the opportunity to receive a copy of Casey Sayre Orthodontics Notice of Privacy Practices. By signing below I am giving acknowledgment that I have received or have had the opportunity to receive the Notice of our Privacy Practices. 




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