New Patient Info Form - Bennett Orthodontics

Is the patient under 18?*

Yes
No

Patient Information

Patient's Name*

Prefers To Be Called

Mailing Address*

Mailing Address Address Line 2 City State ZIP Code

Home Phone*

Date Of Birth*

Sex

Male
Female

SSN*

School

Grade

Email

Whom may we thank for referring you to our office?

Name and age of other siblings?

Responsible Party Information

Name*

Marital Status

Single
Married
Divorced
Widowed

Relationship to Patient

SSN*

Date Of Birth*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

How long at this address?

Do you own or rent?

Own
Rent

Have you been at this address for more than 3 years?*

Yes
No

Previous Address

Previous Address Address Line 2 City State ZIP Code

Home Phone*

Work Phone

Cell/Pager

Employer

Occupation

Number Of Years Employed

Spouse's Name

Relationship to Patient

SSN

Date Of Birth

Email

Work Phone

Cell/Pager

Employer

Occupation

Number Of Years Employed

Dental Insurance Information

Do you have dental insurance?*

Yes
No

Insured's Full Name*

SSN*

Date Of Birth*

Insurance Company*

Group Number

Contract/ID Number

Insurance Complete Address*

Insurance Complete Address Address Line 2 City State ZIP Code

Insurance Phone*

Insured's Employer

Employer's Complete Address

Employer's Complete Address Address Line 2 City State ZIP Code

Employer's Phone

Do you have dual coverage?*

Yes
No

Insured's Full Name*

SSN*

Date Of Birth*

Insurance Company*

Group Number

Contract/ID Number

Insurance Complete Address*

Insurance Complete Address Address Line 2 City State ZIP Code

Insurance Phone*

Insured's Employer

Employer's Complete Address

Employer's Complete Address Address Line 2 City State ZIP Code

Employer's Phone

Emergency Contact Information

Emergency Contact*

Emergency Contact Address

Emergency Contact Address Address Line 2 City State ZIP Code

Emergency Contact Phone*

Medical and Dental Health Information

Patient's Dentist

Date Of Last Dental Visit

Do you need a referral to a dentist?

Yes
No

What concerns you the most about your teeth?

Has an orthodontist previously been consulted?

Yes
No

Are antibiotics necessary for teeth cleaning?

Yes
No

Is there any dental work that needs to be completed prior to orthodontic treatment?

Yes
No

Patient's Physician

Date Of Last Physical Exam

Is the patient under the care of a physician at this time? If yes, please explain.

List any medications being taken at this time.

List all allergies.

Has the patient ever had any of the following medical or dental problems?

Please explain any medical or dental problems that you have had:

Affirmation

Affirmation*

I affirm that the information that I have giiven is correct to the best of my knowledge. It will be held in the strictest of confiidence and it iis my responsiibility to inform this office immediately of any changes in medical status. I understand that where appropriate, credit reports may be obtained.*

Patient/Parent/Legal Guardian*

Date Submitted*