Adult Patient Form

Adult Registration Form - Ortho

Patient Information

Gender

Primary Phone:

Dental History

General Dentist:
How did you hear about our Practice?
What are the main concerns you would like orthodontics to accomplish?
Have you visited an orthodontist before?
Do you have any missing or extra permanent teeth?
Do you smoke?
Do you like your smile?
Do you currently or have you ever had any of the following (check all that apply)











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:
(Women) Are you pregnant?
Check if you have or have ever had any of the following:

Privacy Information

We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly.

I agree that Dr. J. Peterson and/or members or her staff have permission to release information concerning my dental/orthodontic health to the family physician, dentist or any other dental specialist as is deemed necessary from time to time. Such information includes x-rays and other diagnostic records which pertain to the initial condition, diagnosis, proposed treatment or treatment in progress.





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