Adult Patient Form | North Shore Orthodontics
  
  
   

Adult Patient Form

About You

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About Your Employer

Sopuse Information

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Responsible Party Info

Primary Emergency Contact

Primary Dental Insurance

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Orthodontic Coverage

Secondary Dental Insurance

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Orthodontic Coverage

Dental History

Are you currently in pain?
Your current dental health is
Have you ever had a serious/difficult problem associated with previous dental work?
Have you ever had any pain or tenderness in the jaw joint (TMJ/TMD)?
Do you like your smile?
Do your gums ever bleed?
Types of bristles?

Medical History

Do you have a personal physician?
Your current physical health is
Are you currently under the care of a doctor?
Are you taking any prescription drugs?

For Woman Only

Are you taking birth control pills?
Are you nursing?
Are you pregnant?

Have you ever had any of the following diseases or medical problems?

Medical Problems

Are you allergic to any of the following

Allergic Problems

Our Office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.

Consent(Required)

Payment is due in full at time of treatment unless prior arrangements have been approved.