South Texas Orthodontics Adult Registration

Patient Name:

Gender:

Birth Date:

Age:

Home Address:

City:

State:

Zip:

Primary Phone Number:

Phone Type:

Ok to leave message?:

Email:

Employer's Name:

Occupation:

Spouse/Partner's Name:

Marital Status:

Birth Date:

Home Address:

City:

State:

Zip:

Primary Phone Number:

Phone Type:

Secondary Phone Number:

Phone Type:

Emergency Contact's Name::

Phone Number:

Relation to patient:

Home Address:

City:

State:

Zip:

Person(s) OK to release appointment or medically-related information to:

Relation to Patient:

Primary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay(if known):

Deductible (if known):

Policy Holder's Name:

Relation to patient:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Secondary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay(if known):

Deductible (if known):

Policy Holder's Name:

Relation to patient:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

General dentist:

Last Visit:

Name of person referring (if applicable):

How did you hear about our practice:

Ad

Internet

Friend/Family

Physician

Other

What are the main concerns you would like orthodontics to correct?:

Have you visited an orthodontist before?:

Yes No

If yes, when:

Reason:

Have we treated any other family members?:

Yes No

Name:

Have your child's tonsils or adenoids been removed?:

Yes No

Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?:

Yes No

Do you have any missing or extra permanent teeth?:

Yes No

Have you ever had an injury to (select all that apply):

Teeth

Mouth

Chin

Do you have speech problems?:

Yes No

If so, explain:

Do your gums bleed?:

Yes No

Do you smoke?:

Yes No

Do you like your smile?:

Yes No

Do you currently or have you ever had any of the following habits (check all that apply):

Clenching/Grinding Teeth

Lip Sucking/Biting

Mouth Breathing

Nail Biting

Thumb/Finger Sucking

Chewing/Eating Problem

Are you currently being treated by a physician?:

Yes No

Reason:

Physician:

Last Visit:

Phone:

Do you have any allergies/sensitivities to medications or latex?:

Yes No

If yes, please list:

Are you currently taking any prescription or over-the-counter medications?:

Yes No

If yes, please list with the dosage:

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)?:

Yes No

Have you had any serious illnesses or operations? If yes, describe:

Have you ever had a blood transfusion?:

Yes No

If yes, give approximate dates:

(Women) Are you pregnant?:

Yes No

Nursing?:

Yes No

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 child's medical status.

I hereby authorize the release of any information pertaining to my child's 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.

Submitted by:

Date: