Adult New Patient Information

Adult Registration Form - Ortho
* required field

Patient Information

Male Female





Primary Phone Number




Spouse/Emergency Contact Information

Marital Status








How did you hear about our Practice?

Insurance Information



















Dental History


What are the main concerns you would like Dr. Shults to address
Have you visited an orthodontist before


Have you ever experienced jaw joint pain or discomfort (TMJ/TMD)
Do you have any missing or extra permanent teeth
Have you had an injury to (select all that apply):
Do you have speech concerns
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

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)
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. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.




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