Adult Treatment Form

Family Information

Spouse/Partner's Name:

Do you have any children? If so, what are their names and ages?

Social Security Number:

Birth Date:

Driver's License Number:

Address (if different than patient):

City:

State:

Zip:

Primary Phone:

Phone Type: Home Cell

Secondary Phone:

Phone Type: Home Cell

Emergency Contact Information

*Emergency Contact's Name:

* Phone Number:

* Relation to Patient:

*Address:

*City:

* State:

* Zip:

* Person(s) OK to release appointment or medically-related information to:

* Relation to Patient:

Insurance Information

Primary Dental Insurance

Dental Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Secondary Dental Insurance

Secondary Dental Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Dental History

* General Dentist:

* Last Visit:

* Other dentist :

* How often do you brush?:

* How often do you floss?

* What are the main concerns you would like orthodontics to correct?

* Have you visited an orthodontist before? Yes No

* If yes, when:

* Reason:

* Have we treated any other family members? Yes No

* If yes, when:

* 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

* Do you have speech problems? Yes No

* If so, explain:

* How do you feel about orthodontic treatment?:

* 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 (check all that apply): Clenching/Grinding Teeth Lip Sucking/Biting Mouth Breathing Nail Biting Thumb/Finger Sucking Chewing/Eating Problem

* Medical History

* Are you currently being treated by a physician? Yes No

* Reason:

* Patient’s Physician:

* Last Visit:

* Phone:

* Do you have any diagnosed or suspected emotional, sensory, or developmental conditions? Yes No

* If yes, please list:

* Do you have any allergies/sensitivities to medications, metal, or latex? Yes No

* If yes, please list:

* Are you currently taking any prescription or over-the-counter medications? Yes No

* If yes, please list with the dosage:

* Have you ever taken oral medication for bone disorders or cancers such as bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate), or Didronel (etidronate)? Yes No

* Have you had any serious illnesses or operations? If yes, describe:

* FOR WOMEN (select all that apply) Pregnant Nursing Taking birth control pills

* If any of the medical condition boxes are checked provide more details, please. :

Submission Statement

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 understand the release of any information pertaining to my medical treatment may be necessary to process any insurance claims and that Weisner Orthodontics may submit 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.

Submitted by:

Date:

Adult Treatment Form

Patient Information

Family Information

Emergency Contact Information

Insurance Information

Primary Dental Insurance

Secondary Dental Insurance

Dental History

* Medical History

Submission Statement

Methuen Office

North Andover Office

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