Adult Form

_2017 Adult Registration Form – Ortho

Patient Information

Gender:
 
Phone Type

Spouse / Partner Information

Marital Status:
Address (if different than patient):
Phone Type:
Phone Type:

Emergency Contact Information

Insurance Information

Primary Insurance

Policy Holder's Name:

Secondary Insurance

 
 

Dental History

How did you hear about our practice?
Have you visited an orthodontist before?
Have your tonsils or adenoids been removed?
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Do you have any missing or extra permanent teeth?
Have you ever had an injury to (select all that apply):
Do you have speech problems?
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 (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 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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Hartsock and Sword Orthodontics

  • Hartsock and Sword Orthodontics - 161 College St., Suite 3, Pikeville, KY 41501 Phone: 606-432-3603 Fax: 606-432-5330

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