Adult New Patient Information

Adult Registration Form - Ortho

Patient Information

Gender


Primary Phone:

Secondary Phone:


Spouse / Partner Information

Marital Status



Insurance Information


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Dental History

General Dentist:
How did you hear about our Practice?
What are the main concerns you would like orthodontics to accomplish?
Is a family member currently in treatment?Has a family member received treatment in our office?
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 had any serious illnesses or operations? If yes, describe:
Have you ever had a blood transfusion?
(Women) Are you pregnant?
Check if you have or 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.



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ELD Orthodontics

  • Kendallville - 1919 Dowling St., Kendallville, IN 46755 Phone: 260.347.5575
  • Angola - 610 Wayne Plaza, Angola, IN 46703 Phone: 260.665.9534

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