Adult New Patient Form

lexbraces.com - Adult Registration Form

Patient Information

Gender:
Phone Type

Spouse / Partner Information

Marital Status
Phone Type:

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.

Insurance Information

Primary Insurance

Does this policy have orthodontic benefits?

Secondary Insurance

Does this policy have orthodontic benefits?

Dental History

Have you visited an orthodontist before?
Have we treated any other family members?
Have you ever had an injury to (select all that apply):
Do you have any missing or extra permanent teeth?
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Select all that apply:
Check if you have or ever had any of the following:

Medical History

Are you currently being treated by a physician for any condition?
Are you currently taking any prescription or over-the-counter medications?
Check if you have or ever had any of the following:
Have you had allergies or reactions to any of the following?
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?

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.



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Lexington Orthodontics

  • Lexington Orthodontics - 24 Muzzey Street, Lexington, MA 02421 Phone: 781-862-2625 Fax: 781-862-9169

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