Adult Orthodontic Consultation Form

ADULT ORTHODONTIC CONSULTATION FORM

(PLEASE PRINT) DATE______

PATIENT’S NAME ______

SURNAME GIVEN NAME INITIAL PREFERED

DATE OF BIRTH ______AGE ______GENDER ______

MONTH/DAY/YEAR

ADDRESS ______

NO. STREETCITY OR TOWNPOSTAL CODE

HOME # ______WORK # ______CELL#______

EMAIL ADDRESS:______

NAME OF EMPLOYER______

WHO REFERRED YOU TO THIS OFFICE? ______

WHO FIRST NOTICED THE NEED FOR ORTHODONTIC CARE? ______

REASON FOR ORTHODONTIC CONSULTATION ______

______

HAVE YOU HAD PREVIOUS ORTHODONTIC TREATMENT? □ YES□ NO

FOR YOU TO HAVE ORTHODONTIC THERAPY, DO YOU CONSIDER IT: □ Necessary □ Important □ Desirable □ Indifferent

DO YOU HAVE ANY CONCERNS REGARDING ORTHODONTIC TREATMENT?

______

HAS ANYONE ELSE IN THE FAMILY HAD OR HAVING ORTHODONTIC THERAPY? ______

IF YES, WHO? ______WHEN? ______AND BY WHOM? ______

HOW HAPPY ARE YOU ABOUT THE TREATMENT RESULTS? ______

______

PERSON FINANCIALLY RESPONSIBLE: □ THE PATIENT OR

NAME ______

SURNAMEGIVEN NAME

ADDRESS ______

NO. STREET CITY OR TOWN POSTAL CODE

HOME PHONE ______BUS. PHONE ______NAME OF EMPLOYER______

DO YOU HAVE INSURANCE, IF SO NAME OF INSURANCE______

NAME OF POLICY HOLDER ______

MEDICAL HISTORY

(PLEASE EXPLAIN ALL “YES” ANSWERS)

PHYSICIAN’S NAME ______

ADDRESS ______PHONE ______

CURRENTLY UNDER PHYSICIAN’S CARE? □ NO □ YES______

CURRENTLY TAKING MEDICATION?□ NO □ YES______

CURRENTLY UNDER PSYCHOLOGICAL GUIDANCE?□ NO □ YES______

DO YOU HAVE ANY OF THE FOLLOWING ILLNESSES?

JAUNDICE□ NO □ YES ______

HEPATITIS□ NO □ YES______

RHEUMATIC FEVER□ NO □ YES______

OVER→

MEDICAL HISTORY CON’T

OTHER SEVERE ILLNESSES□ NO □ YES______

REMOVAL OF TONSILS AND/OR ADENOIDS□ NO □ YES______

OTHER OPERATIONS □ NO □ YES______

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS?

AIDS OR CARRIER OF THE AIDS VIRUS? □ NO □ YES______

ASTHMA□ NO □ YES______

ALLERGIES - INCLUDING LATEX OR NICKEL□ NO □ YES______

BIRTH DEFECTS□ NO □ YES______

BLOOD DISORDERS □ NO □ YES______

EPILEPSY□ NO □ YES______

DIABETES□ NO □ YES______

HEART AND/OR LUNG CONDITIONS□ NO □ YES______

FREQUENT □ COLDS □ SORE THROATS□ NO □ YES______

PREGNANT OR THE POSSIBLITY□ NO □ YES______

OTHER MEDICAL CONDITIONS NOT LISTED□ NO □ YES______

MECICATIONS: □ NO □ YES______

DENTAL HISTORY

(PLEASE EXPLAIN ALL “YES” ANSWERS)

DENTIST’S NAME ______

ADDRESS ______PHONE ______

HOW LONG HAVE YOU BEEN GOING TO THE ABOVE DENTIST? ______

HOW OFTEN DO YOU GO TO YOUR DENTIST? ______

WHEN WAS YOUR LAST DENTIST APPOINTMENT? ______

HAVE YOU HAD A RECENT ORTHODONTIC EXAMINATION? ______

DO YOU OR DID YOU HAVE ANY OF THE FOLLOWING

INJURY TO HEAD, FACE, MOUTH OR TEETH?□ NO □ YES______

CLICKING OR DISCOMFORT IN THE JAW?□ NO □ YES______

GRINDING OR CLENCHING OF TEETH? □ NO □ YES______

RECURRENT HEADACHES?□ NO □ YES______

DIFFICULTY IN CHEWING? □ NO □ YES______

SPEECH PROBLEMS? □ NO □ YES______

EXTENSIVE DENTAL WORK OR GUM PROBLEMS?□ NO □ YES______

ARE YOU CONCERNED OR HAVE RESERVATIONS ABOUT

APPREARANCE OF YOUR □ FACE □ LIPS □ GUM □ TEETH?□ NO □ YES______

WEARING □ BRACES □ NO □ YES______

CO-OPERATION FOR APPROX. 2 YEARS?□ NO □YES______

APPOINTMENTS DURING BUSINESS HRS?□ NO □ YES______

SIGNATURE ____________

PLEASE NOTE: IT IS IMPORTANT THAT YOU COMPLETE AND BRING THIS FORM TO YOUR APPOINTMENT OR YOU CAN FAX IT TO (709)-489-1435 OR EMAIL:

IT IS THE POLICY OF THIS OFFICE TO BILL AND RECEIVE FULL PAYMENT FROM OUR PATIENTS. WE REQUIRE THAT YOU MAKE PAYMENTS FROM YOUR INSURANCE COMPANY PAYABLE TO YOU. WE HAVE STANDARD FORMS IN OUR OFFICE FOR YOUR USE.