Adult New Patient Intake Form

Please complete this form at least 24 hours prior to your appointment with us so that we may better serve you.

Today's Date
Date Format: MM slash DD slash YYYY
Name
First Middle Last
Name you prefer to be called
Home Address
Street Address Address Line 2 City State ZIP Code
Billing Address (if different from Home Address)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Birth Date
Date Format: MM slash DD slash YYYY
Age
Gender
- Male
- Female
Email Address
Enter Email Confirm Email
Cell Phone Number
Home Phone Number
Employer
Work Phone Number
Whom may we thank for referring you?
General Dentist Name
Last Visit date to Dentist (approximate)
Insurance / Billing Information
INSURANCE - Do you have orthodontic coverage?
- Yes
- No
Insurance Company Name
Insurance Company Address
Street Address Address Line 2 City State ZIP Code
Insurance Company Phone Number
Group Number (Plan, Local or Policy #)
Member/Subscriber ID#
Policy Owner's Name
First Last
Relationship to You
Policy Holder's Social Security Number (required to file some insurances)
This is a secure site and all information will be kept strictly confidential.
Policy Owner's Birthdate
Date Format: MM slash DD slash YYYY
Policy Owner's Employer
Employer's Address
Street Address Address Line 2 City State ZIP Code
Objectives and Patient Medical Information
What are the main concerns that you would like orthodontics to accomplish?
Have you ever been evaluated or had orthodontic treatment before?
- Yes
- No
Have there been any injuries to your face, mouth, teeth, or chin?
- Yes
- No
If you answered yes, please give a brief description
Have your adenoids or tonsils been removed?
- Yes
- No
Have you been informed of any missing or extra permanent teeth?
- Yes
- No
Have you ever had any pain/tenderness in your jaw joint (TMJ/TMD)?
- Yes
- No
Are you currently under the care of a physician?
- Yes
- No
Physician's Name
First Last
Physician's Phone Number
Date of Last Visit (approximate)
Please describe your current physical health:
- Good
- Fair
- Poor
Please list all drugs that you are currently taking:
Please list all drugs / things that you are allergic to:
Allergic to Latex?
- Yes
- No
Allergic to Metals/Nickel?
- Yes
- No
Allergic to Plastics?
- Yes
- No
- Third Choice
Please check any of the following medical problems that you have ever had:
- Abnormal Bleeding
- ADD / ADHD
- Allergies to any Drugs
- Allergies to Latex / Metals
- Allergic to Plastic
- Any Hospital Stays
- Any Operations
- Artificial Bones / Joints / Valves
- Asthma
- Cancer
- Congenital Heart Defect
- Convulsions / Epilepsy
- Diabetes
- Handicaps / Disabilities
- Hearing Impairment
- Heart Murmur
- Hemophilia
- Hepatitis
- HIV+ / AIDS
- Kidney / Liver Problems
- Lupus
- Rheumatic / Scarlet Fever
- Tuberculosis (TB)
- None
Please discuss any medical problems that you have had:
Please check any of the following that you have ever experienced:
- Clenching / Grinding Teeth
- Lip Sucking / Biting
- Mouth Breather
- Nail Biting
- Nursing Bottle Habits
- Speech Problems
- Thumb / Finger Sucking
- Tongue Thrust
- None
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status.

Insurance / Billing Information

Objectives and Patient Medical Information

Bentley Orthodontics