Adult New Patient Information

* required field

Patient Name (First and Last)

Prefer to be called

Gender Male
Female

Birthdate - mm/dd/yyyy

Age

Address

City

Province

Postal Code

Home Phone

Work Phone

Cell Phone

E-mail address *

List any family members that are patients in our office

How did you hear about our office
Other

Whom may we thank for referring you to our office?

Person responsible for the account

Do you have an insurance plan that covers orthodontic treatment? Yes
No
Not Sure

Primary Insurance Name

Policy Holder Name

Policy Holder Birthdate - mm/dd/yyyy

Relationship to patient

Group/Policy Number

ID/Certificate Number

Lifetime Maximum

Percentage Payable

What is the Age Restriction

Secondary Insurance Name

Policy Holder Name

Policy Holder Birthdate - mm/dd/yyyy

Relationship to patient

Group/Policy Number

ID/Certificate Number

Lifetime Maximum

Percentage Payable

What is the Age Restriction

Patient Information

Insurance Information

Dental History

Medical History