Adult Registration Form

South Texas Adult Registration Form

Patient Information

Gender:
Phone Type
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Spouse / Partner Information

Marital Status:
Phone Type:
Phone Type:

Emergency Contact Information

Insurance Information

Primary Insurance

Secondary Insurance

Dental History

How did you hear about our practice?
Have you visited an orthodontist before?
Have your tonsils or adenoids been removed?
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):
Do you have speech problems?
Do your gums bleed?
Do you smoke?
Do you like your smile?
Do you currently or have you ever had any of the following habits (check all that apply):

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 lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Have you ever had a blood transfusion?
(Women) Are you pregnant?
Nursing?
Taking birth control pills?
Check if you have ever had any of the following:

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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Testimonial 1

“I highly recommend South Texas Orthodontics! The staff is always friendly, quick and professional. Thank you for your great customer service.”

~ Daisy A.

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Testimonial 2

“I LOVE this place! As an adult getting braces, I was unsure what to expect. My teeth look amazing and I owe it all to Dr. B and his awesome staff!”

~ Cassandra A.

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Testimonial 3

“My 11-year-old and I have consistently had a wonderful experience with South Texas Orthodontics. Dr. Jackson is calm, professional and very pleasant to work with. The front desk staff is attentive and always engaging. We will be starting our 2nd phase of braces soon and are confident that it will go just as well as the first time. I would highly recommend this practice for all your ortho needs!”

~ Gloria S

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Testimonial 4

“This is my 2nd time getting braces here! Love the doctors and staff! They are great at getting you in for last minute appointments and working with your schedule. They really care! Love this place!”

~ Gena S.

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Testimonial 5

“Our experience at South Texas Orthodontics has been wonderful! The staff were helpful, knowledgeable and now our daughter has a beautiful smile to show for it. I recommend this office and Dr. Bruchmiller to anyone needing braces/orthodontic work.”

~ Jared and Mylia R.

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Testimonial 6

“My son, daughter and I all got our braces done here with Dr. Jackson. Glad I went with Dr. Jackson! Everyone here is personable and makes you feel comfortable, even if you get a different assistant every time. Dr. Jackson explains to you what needs to be done and how she's going to do it to get the results that need to be achieved. I wouldn't go anywhere else!”

~ Michele G.

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