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710 Federal Dr. Selmer, TN 38375
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Your First Orthodontic Appointment
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Adult Treatment
Types of Braces
Invisalign
Foods to Avoid
Retention
Contact Us
Home
Office Info
About Our Doctors
Our Staff
Office Policies
Financial
Map and Directions
Related Links
Appointment Request
Patient
Patient Forms
FAQ’s
Common Problems
Emergencies
Oral Hygiene
Dental Treatment
First Visit
Your Teeth
General Treatment
Early Dental Care
Dental Implants
CEREC
Crowns & Bridges
Teeth Whitening
Veneers & Bonding
Root Canals
TMJ/TMD
Gum Rejuvenation
Dentures
Partial Dentures
Implant-Retained Dentures
Prevention
Sedation Dentistry
Before and After
Orthodontics
When to See About Orthodontics
Your First Orthodontic Appointment
Early Treatment
Adolescent Treatment
Adult Treatment
Types of Braces
Invisalign
Foods to Avoid
Retention
Contact Us
710 Federal Dr. Selmer, TN 38375
Adult Ortho Patient Form
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Adult Ortho Patient Form
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Patient Information
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Patient Name: (Required)
Gender
Male
Female
Social Security Number
Birth Date
Driver's License Number
Home Address
City
State
Zip
Primary Phone Number
Phone Type
Home
Cell
Secondary Phone Number
Phone Type
Home
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Other
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E-mail Address:(Required)
Employer's Name
Occupation
Spouse/Emergency Contact Information
Marital Status
Marital Status
Single
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Significant Other
Spouse/Partner's Name
Emergency Contact Name
Phone Number
Relation to you
Address
City
State
Zip
Person(s) OK to release appointment or medically related information to concerning you.
Relation
Insurance Information
Primary Insurance Company
Phone Number
Group Number
Policy Number
Member ID Number
Policy Holder's Name
Relation
Policy Holder's Social Security Number
Policy Holder's Birth Date
Employer
Work Phone Number
Co-pay (if known)
Deductible (if known)
Secondary Insurance Company
Phone Number
Group Number
Policy Number
Member ID Number
Policy Holder's Name
Relation
Policy Holder's Social Security Number
Policy Holder's Birth Date
Employer
Work Phone Number
Co-pay (if known)
Deductible (if known)
Dental History
General Dentist
Last Visit
How did you hear about our Practice?
Ad
Internet
Family or Friend
Physician
Other
Name of person referring (if applicable) :
What are the main concerns you would like orthodontics to accomplish?
Have you visited an orthodontist before?
Yes
No
When?
Reason?
Have your tonsils or adenoids been removed?
Yes
No
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Yes
No
Do you have any missing or extra permanent teeth?
Yes
No
Have you ever had an injury to (select all that apply):
Teeth
Mouth
Chin
Do you have speech problems?
Yes
No
If so, explain:
Do your gums bleed?
Yes
No
Do you smoke?
Yes
No
Do you like your smile?
Yes
No
Do you currently or have you ever had any of the following habits?
Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail biting
Thumb/ Finger Sucking
Chewing/Eating Problems
Medical History
Are you currently being treated by a physician?
Yes
No
Reason
Physician
Last Visit
Phone
Do you have any allergies/sensitivities to medications or latex?
Yes
No
If yes, please list allergies
Are you currently taking any prescription or over-the-counter medications?
Yes
No
Please list, with dosage
Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Yes
No
Have you had any serious illnesses or operations? If yes, describe:
Have you had any serious illnesses or operations? If yes, describe
Have you ever had a blood transfusion?
Yes
No
If yes, give approximate dates:
(Women)
Are you pregnant?
Yes
No
Nursing?
Yes
No
Taking birth control pills?
Yes
No
Check if you have or have ever had any of the following:
Anemia
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back Problems
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Cortisone Treatments
Cough, Persistent
Coughing Blood
Diabetes
Epilepsy
Fainting
Glaucoma
Headaches
Heart Murmur
Heart Problems
Hemophilia
Hepatitis
High Blood Pressure
HIV/AIDS
Jaw Pain
Kidney Disease
Liver Disease
Mitral Valve Prolapse
Pacemaker
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Skin Rash
Stroke
Swelling of Feet or Ankles
Thyroid Problems
Tobacco Habit
Tonsillitis
Tuberculosis
Ulcer
Venereal Disease
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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