Adult Patient Form

Patient Information

* Patient First Name: (Required)

* Patient Last Name: (Required)

* Patient Prefers to be Called:

Gender: Male Female

Birth Date:

Age:

Home Address:

City:

State:

Zip:

Primary Phone Number:

Phone Type home cell

E-mail:

Spouse / Partner Information

Spouse/Partner First Name:

Spouse/Partner Last Name:

Address (if different than patient's):

City:

State:

Zip:

Primary Phone:

Phone Type: home cell

Unencrypted email is not a secure form of communication. There is an inherent risk that content contained in such email/text messages may be misdirected, disclosed to or intercepted by, unauthorized third parties. Lexington Orthodontics will use the minimum necessary amount of protected health information in any communication. I agree that I am responsible for providing the dental practice any updates to my email address and/or mobile phone number.

Dental Insurance Information

Primary Dental Insurance

Primary Insurance Company:

Address:

Phone Number:

Group Number:

Member ID Number:

Policy Holder's Name:

Relation to Patient:

Policy Holder's Date of Birth:

Employer:

Does this policy have orthodontic benefits? Yes No

Secondary Dental Insurance

Secondary Insurance Company:

Phone Number:

Group Number:

Member ID Number:

Policy Holder's Name:

Relation to Patient:

Policy Holder's Date of Birth:

Employer:

Does this policy have orthodontic benefits? Yes No

Dental History

General Dentist:

Date of Last Visit:

Who suggested that you might need orthodontic treatment?

What are your main concerns about your teeth?

Have you visited an orthodontist before? Yes No

If yes, when?: Reason:

Have we treated any other family members? Yes No

Name:

Have you ever had an injury to (select all that apply): Teeth Mouth Chin

If yes, please explain:

Do you have any missing or extra permanent teeth? Yes No

Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)? Yes No

Select all that apply: Clenching/grinding of teeth Clicking/popping sounds in the jaw joint Inability to open/close mouth normally Jaw getting locked/stuck

Check if you have or ever had any of the following: Frequent canker sores or cold sores Enlarged Tonsils / Adenoids Thumb / Finger Sucking Difficulty breathing through nose Mouth breathing habit Snoring / Sleep Apnea

Medical History

Are you currently being treated by a physician for any condition? Yes No

If yes, please explain:

Physician:

Date of Last Visit:

Phone:

Are you currently taking any prescription or over-the-counter medications? Yes No

If yes, please list with the dosage:

Have you had any serious illnesses or operations? If yes, describe:

Have you had allergies or reactions to any of the following? Local anesthetics (novocaine, lidocaine, xylocaine) Latex (gloves, balloons) Metals/Nickel (jewelry, clothing snaps) Acrylic

Any other allergies (please list):

Have you ever taken intravenous bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate) or oral bisphosphonates such as Fosamax (alendronate), Actonel(ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders or cancer? Yes No

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.

Submitted by:

Date: