New Patient Form

Patient Information








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Responsible Party Information







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Dental Insurance Information


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Emergency Information




Medical History






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Abnormal bleeding/HemophiliaDiabetesHepatitis/Liver problemsPneumoniaAnemiaDizzinessHerpesProlongedBleedingArthritisEpilepsyHigh Blood PressureRadiation/ChemotherapyAsthma or HayfeverGastrointestinal DisordersHIV / AidRheumatic FeverBone DisordersHeart ProblemsKidney problemsTuberculosisCongenital Heart DefectHeart MurmurNervous DisordersTumor or Cancer



LatexPenicillinCodeineErythromycinTetracyclineAspirinIbuprofenMetalsOther


RheumFeverProsthesisConvulsions/epilepsyHearing impairmentHandicaps/disabilitiesHistory of Scarlet Fever


Thumb sucking/Finger suckinglip Sucking/bitingNail bitingNursing Bottle HabitsTrouble chewing


Dental History





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If yes, who and when?


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How did they feel about the result?

What is your attitude toward receiving orthodontic treatment?


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Height of parents? Mom   Dad


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Female Patients only:


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BENEFITS

Benefits of Orthodontics: Aesthetics, Health and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result.
Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph, I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. to perform a complete orthodontic evaluation.

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