New Patient Form for Adults Today's Date(Required) MM slash DD slash YYYY Name(Required) First Last I Prefer to be Called Male or Female?(Required)MaleFemaleBirth Date(Required) MM slash DD slash YYYY SS # Home Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Marital Status(Required)SingleMarriedDivorcedHome #(Required)Cell #(Required)Email(Required) Employer Occupation Whom may we thank for referring you? General Dentist(Required) Last Visit Date(Required) MM slash DD slash YYYY Orthodontic Coverage(Required)YesNoI Don't KnowInsurance Co. Name(Required) Insurance Co. Address City Insurance Co. Phone(Required)Group #(Required) Insured's Name(Required) First Last Insured's Birth Date(Required) Insured's ID or SS# Insured's Employer His/Her Name Relation Contact Phone(Required)What are the Main Concerns that you would like Orthodontics to Address?(Required) Do you have a personal Physician?(Required) Physician's Name Phone #Date of Last Visit MM slash DD slash YYYY Are you taking any prescription drugs?(Required) Please List Are You Pregnant?(Required)YesNoAre You Nursing?(Required)YesNoDo You Have any Known Allergies?(Required)YesNoPlease list Have you ever had or been evaluated for orthodontic treatment?(Required) Have you ever had a serious/difficult problem associated with any previous dental work?(Required) Do you now or have ever experienced pain in our jaw joint? (TMD)(Required) Have you ever had an injury to your mouth/teeth/face?(Required) Do you have any speech problems?(Required) Do you clench or grind your teeth?(Required) Do you have any missing or extra permanent teeth that you know of?(Required) Anemia/Radiation Treatment(Required) Artifical Bones/Joints(Required) Artificial Valves(Required) Asthma/Arthritis(Required) Blood Transfusion(Required) Cancer/Chemotherapy(Required) Congenital Heart Defect(Required) Diabetes/Tuberculosis(Required) Difficult Breathing(Required) Drug/Alcohol Abuse(Required) Emphysema/Glaucoma(Required) Epilepsy/Seizures(Required) Fever Blisters/Herpes(Required) Heart Attack/Stroke(Required) Heart Murmur(Required) Heart Surgery/Pacemaker(Required) Hemophilia/Abnormal Bleeding(Required) Hepatitis(Required) High/Low Blood Pressure(Required) HIV/AIDS(Required) Hospitalizations(Required) Kidney Problems(Required) Mitral Valve Prolapse(Required) Psychiatric Problems(Required) Rheumatic/Scarlet Fever(Required) Severe/Frequent Headaches(Required) Shingles(Required) Sinus Problems(Required) Ulcers/Colitis(Required) Please list any serious medical conditions that you have ever had:(Required) Signature
