New Patient Form

Location

Hutto

Steiner Ranch

Full Name

Date of Birth

Gender

Male

Female

General Dentist

Address

City

State

Zip

Phone

How did you hear about us?

Dentist

Location

Friend

Family

Other

If other, please specify

Any friends or family members currently a patient with us?

Responsible Party Information

Please check here if the patient is also the responsible party. Otherwise, continue with this section.

Name

Date of Birth

Relationship

Phone

Address, if different from above

City

State

Zip

Insurance Information

Please check here if patient has medicaid/chip or no dental insurance.

Policy Holder

Date of Birth

Relationship To Patient

Insurance Company

Employer

Member ID or SS#

Group #

Insurance Company Phone #

Please check here if there is secondary insurance coverage. Continue with this section.

Secondary Policy Holder

Date of Birth

Relationship To Patient

Insurance Company

Employer

Member ID or SS #

Group #

Insurance Company Phone #

Patient Health History

Speech therapy/problems

Yes

Clinching or grinding of teeth

Yes

Missing or extra permanent teeth

Yes

Oral habits (thumb sucking, lip or nail biting, or extended pacifier use)

Yes

Injury to face, jaw, teeth, or mouth

Yes

Teeth sensitive to hot or cold temperatures

Yes

Jaw clicking, locking, pain or tenderness

Yes

Previous root canal therapy

Yes

Heart murmur

Yes

Heart attack or stroke

Yes

Hypertension/high blood pressure

Yes

HIV/AIDS

Yes

Received radiation therapy

Yes

Bone loss / bone disorders

Yes

Seizures/epilepsy/neurological disease

Yes

Taken bisphosphonates (Fosamax, Actonel, Boniva, etc.)

Yes

Autism or social/pyschological issues

Yes

Allergy to latex

Yes

Metal allergy or allergy to ear rings

Yes

Significant dental or medical history not noted above

Yes

If yes, please explain

Emergency Contact

Phone #

Relation

I acknowledge that I have completed this from to the best of my ability and the information is true. I will not hold my orthodontist or any member of the staff responsible for omissions or errors that I may have made during the completion of this form. If there are any changes to this medical record, I understand that I must provide the information to the office in a reasonable time frame (within 30 calendar days)

Signature

Date

Relation

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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