adult

Adult New Patient Information

Patient Information

MaleFemale
HomeCell
HomeCellOther

Spouse/Emergency Contact Information

Marital StatusSingleMarriedDivorcedWidowedSignificant Other

Insurance Information

Secondary Insurance Company

Dental History

How did you hear about our Practice?AdInternetFamily or FriendPhysicianOther
What are the main concerns you would like orthodontics to accomplish?
Have you visited an orthodontist before?YesNo
Have your tonsils or adenoids been removed? YesNo
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)? YesNo
Do you have any missing or extra permanent teeth? YesNo
Have you ever had an injury to (select all that apply):TeethMouthChin
Do you have speech problems? YesNo
Do your gums bleed? YesNo
Do you smoke? YesNo
Do you like your smile? YesNo
Do you currently or have you ever had any of the following habits? Clenching/Grinding TeethLip Sucking/BitingMouth BreathingNail bitingThumb/ Finger SuckingChewing/Eating Problems

Medical History

Are you currently being treated by a physician? YesNo
Do you have any allergies/sensitivities to medications or latex? YesNo
Are you currently taking any prescription or over-the-counter medications? YesNo
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)? YesNo
Have you ever had a blood transfusion? YesNo

Women

Are you pregnant? YesNo
Nursing? YesNo
Taking birth control pills? YesNo
Check if you have or have ever had any of the following:AnemiaArthritis, RheumatismArtificial Heart ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseCancerChemical DependencyChemotherapyCirculatory ProblemsCortisone TreatmentsCough, PersistentCoughing BloodDiabetesEpilepsyFaintingGlaucomaHeadachesHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHIV/AIDSJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSkin RashStrokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcerVenereal Disease

Authorization

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.

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Dear Patients,

We have always been at the leading edge of infection control & follow all the CDC, ADA, and AAO guidelines. Our highest priority is keeping all patients and team members safe. Your health and safety is our highest priority. We implement the following health and safety policies:

  • Masks are required to be worn at all times with the exception of during treatment
  • PPE (personal protective equipment) is worn by all team members at all times
  • Pre-screening via questionnaire and infrared thermometer is required for all staff and patients before entering the office
  • Limited numbers of patients/ staff in office at one time

We appreciate your understanding and look forward to seeing you at your next visit!

Sincerely,
Dr. Mendez and the team at All About Smiles Orthodontics