New Patient Registration Form - Orthodontic Practice

Patient Information

• Full Name: _________________ Date: _________________
• Date of Birth: ______________ Age: _____ Gender: _____
• Address: ________________________________________
• City: _____________ State: _____ ZIP: ____________
• Phone (Home): ____________ (Cell): ______________
• Email: ________________________________________
• Emergency Contact: _____________ Phone: __________

Dental History

• General Dentist: _________________________________
• Date of Last Dental Visit: _________________________
• Primary Orthodontic Concern: ______________________

Medical History

Please check if you have/had any of the following:

• Heart Conditions
• High Blood Pressure
• Diabetes
• Bleeding Disorders
• Bone Disorders
• TMJ Problems

Allergies

• Are you allergic to latex? □ Yes □ No
• List other allergies: _____________________________

Insurance Information

• Primary Insurance: ______________________________
• Subscriber Name: ______________________________
• Subscriber ID: _________________________________
• Group Number: ________________________________

Consent

I hereby certify that the information provided is accurate and complete to the best of my knowledge.

Signature: _________________ Date: ________________

Office Policies

• 24-hour notice required for appointment cancellation
• Payment is due at time of service
• Insurance claims filed as a courtesy to patients