Menu

Adult New Patient Information

Adult Registration Form - Ortho

Patient Information

Gender

Primary Phone:

Insurance Information

 
Dental History
General Dentist:
How did you hear about our Practice?
What are the main concerns you would like orthodontics to accomplish?
Have you visited an orthodontist before?
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 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:

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.



Security Measure

Hartsock Orthodontics

  • Hartsock Orthodontics - 161 College St., Suite 3, Pikeville, KY 41501 Phone: 606.432.3603

2018 © All Rights Reserved | Privacy Policy | Website Design By: West | Login