Adult Registration Form | Dr. Bath Orthodontics

Patient Information

* Patient Name: (Required)

Gender: Male Female

Birth Date:

Age:

Home Address:

City:

State:

Zip:

* Cell Phone Number:

* E-mail: (Required)

Employer's Name:

Occupation:

Spouse / Partner Information

Birth Date:

Address (if different than patient):

City:

State:

Zip:

Cell Phone:

Dental Insurance Information

Primary Dental Insurance

Primary 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:

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:

Dental History

General Dentist:

Name of person referring (if applicable):

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

Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)? 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 you smoke? 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:

Do you have any allergies/sensitivities to medications 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:

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)? Yes No

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

(Women) Are you pregnant? Yes No

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.

Submitted by:

Date: