Adult New Patient Form

Please complete the form below before your first visit

Is it ok to release appointment or medically related information concerning you?
How did you hear about us?
What are the main concerns you would like an orthodontist to accomplish?
Have you visited an orthodontist before? If so, when and why?
Do you have or have ever had any of the following? (select all that apply)
Have you ever had an injury to: (select all that apply)
Do you currently or have you ever had any of the following habits? (select all that apply)
Are you currently being treated by a physician? If yes, please include your physician's name, number, reason for treatment, and most recent treatment date.
Do you have any allergies or sensitivities to medications or latex? If yes, please list allergies.
Are you currently taking any prescription or over-the-counter medications? If yes, please list with dosage?
Have you had any serious illness or operations? If yes, please describe
Thank you! Your submission has been received!
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Adult New Patient Form

Please complete the form below before your first visit

Patient Name
Patient Last Name
E-Mail
Phone
Social Security Number
Patient Date of Birth
Full Mailing Address
General Dentist
Last General Dentist Visit Date
Employer's Name
Occupation
Dental Insurance Company
Insurance Phone Number
Policy Holder's Name
Policy Holder's Date of Birth
Relationship to Policy Holder
Policy Holder's SSN
Medical ID Number
Group Number
Partner's Name
Partner's Phone Number
Is it okay to release appointment and medically related information concerning you to your partner?
Do you have or have you ever had any of the follow? (select all that apply)
Have you ever had an injury to: (select all that apply)
Do you currently or have you ever had any of the following habits? (select all that apply)
Have your tonsils or adenoids been removed?
Do you have any trouble with sleeping or snoring?
Have you ever experienced jaw joint pain or discomfort? (TMJ/TMD)
Do you have speech problems?
Do your gums bleed?
Do you smoke?
Do you like to smile?
What are the main concerns you would like an orthodontist to accomplish?
Have you visited an orthodontist before? If so, when and why?
Are you currently being treated by a physician? If yes, please include your physician's name, number, reason for treatment, and most recent treatment date.
Do you have any allergies or sensitivities to medications or latex? If yes, please list all allergies.
Are you currently taking any prescription or over-the-counter medications? If yes, please list with dosage.
Have you had any serious illness or operations? If yes, please describe.
How did you hear about us?
Full Name
Date
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
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440-449-5792
29001 Cedar Rd,
Lyndhurst, OH 44124
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