Adult Patient Form

Adult Registration Form - Ortho
* required field

Patient Information

Primary Phone Number 
Secondary Phone Number 

Spouse/Emergency Contact Information

Marital Status

Insurance Information

Dental History

How did you hear about our Practice?
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Do you have any missing or extra permanent teeth?
Have you ever had an injury to (select all that apply):

Gum and Bone health

Do your gums bleed?

Gum disease has been linked with an increased risk for many chronic diseases. Eliminating gum disease is especially important to the oral and overall health of the following patients:

Tobacco User

Tobacco users are more likely to develop gum disease which is more severe and more difficult to eradicate. Gum disease has recently been linked with an increased risk for heart disease


Diabetes is well-known risk factor for gum disease. Research is confirming that when left untreated, gum disease makes it harder to control blood sugar. Elimination of gum disease can improve the blood sugar control, reducing the risk for the serious complications.

Do you have diabetes?

Family history of gum disease

Some people are genetically prone to developing gum disease even if they take decent care of their mouths.

Do you have any family history of gum disease?


Stress is a well-known risk factor for gum altering events (loss of job, death in family,moving,etc) can be particularly strong factors for gum disease.

Is your stress level too high?

Rheumatoid Arthritis

If you have arthritis you are at an increased risk for gum disease. Emerging research suggest that eliminating gum disease and then keeping it at bay can lessen the crippling effects of arthritis.

Have you ever been diagnosed with Rheumatoid Arthritis?

Cosmetic concerns

Do you like your smile?
Are you interested in learning of options to improve your smile?
Have you ever had orthodontic treatment?
Are you interested in straightening your teeth?
Do you like appearance of your teeth/smile?
Do you have discolored teeth?
Do you have crowded teeth?
Would you like to discuss options for improving the appearance of your smile?
Do you currently or have you ever had any of the following habits?

Medical History

Are you currently being treated by a physician?

Do you have any allergies/sensitivities to medications or latex?
Are you currently taking any prescription or over-the-counter medications?
Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Have you had any serious illnesses or operations? If yes, describe:

Check if you have or have ever had any of the following:


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.