Adult New Patient Information

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Adult Registration Form - Ortho
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PATIENT INFORMATION-ADULT



Gender



Primary Phone Number:
Secondary Phone Number:






Spouse/Closest Relative Contact Information

Marital Status







DENTIST/PHYSICIAN






How did you hear about our Practice?

Who is financially responsible for this account?









Do you have Dental Insurance?

Medical History

Now or in the past, have you had:

















(Women)


Do you have allergies or reactions to any of the following:

Aspirin







Do you currently have or ever had a substance abuse problem?
Do you or have you chewed or smoked tobacco?


MEDICATIONS

Have you ever taken Biphosphanate Drugs for Cancer, Osteoporosis or any other condition?

If yes, which one(s):

IV Cancer Drug:
Oral Cancer Drug

PRIOR TO CERTAIN DENTAL PROCEDURES, DO YOU TAKE A PRE-MEDICATION ANTIBIOTIC?

DENTAL HISTORY

Now or in the past have you ever had the following:












Would you mind wearing braces?
Have you been under another specialist care (Periodontist, Endodontist, Oral Surgeon, etc...)?

Has any relative ever had jaw surgery to correct their bite?
Does any relative have an under bite?
How often do you brush a day?
How often do you floss?

 


 

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.


HIPAA ACKNOWLEDGEMENT I acknowledge the Notice of Privacy Practice is available for me to read or print from Embrace Our World Orthodontics through their website. By initialing below, I consent to the use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.



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