Adult Form

West Orthodontics Adult New Patient Information
* required field

Patient Information

Gender *
Primary Phone Number *
Secondary Phone Number

Primary Responsible Party

Relation to Patient *
Please Check One *
Marital Status

Spouse/Secondary Responsible Party

Insurance Information

Do You Have Insurance? *

Secondary Insurance

Dental History

How did you hear about our Practice? *
What are the main concerns you would like orthodontics to accomplish?
Have you visited an orthodontist before? *
What type of orthodontic treatment would the patient prefer? *
Have your tonsils or adenoids been removed? *
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 like your smile? *
Do you currently or have you ever had any of the following habits?
Have you ever had orthodontic treatment?

Medical History

Do you have any allergies/sensitivities to medications or latex?
Are you currently taking any prescription or over-the-counter medications? *

Smoking can have a negative effect on orthodontics. Do you smoke? *

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

Check if you have or have ever had any of the following:


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.

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