New Patient Form – Up North Orthodontics

Submit your health history form online to your orthodontist today. Logo

Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form and click "submit". Your information will be sent to our office with secure encryption. We will have your information when you arrive for your first appointment.

Patient Information

Name*

First Middle Last

Address*

Street Address City State ZIP Code

Home Phone*

Birthdate*

Marital Status*

Sex*

Email

If patient is a minor, parent's / guardian's name

If patient is a minor, name and ages of siblings

Whom may we thank for referring you to our office?

Sports/Hobbies/Musical Instruments

School/Occupation

Current Grade

Nickname

Person Responsible For Account

Same as Above?*

Yes
No

Relationship to Patient*

Name

First Middle Last

Address

Street Address City State ZIP Code

Email

Marital Status*

Home Phone

Birthdate

Have you been at this address longer than 3 years?*

Yes
No

Previous Address

Street Address City State ZIP Code

Work Phone

Cell Phone

Social Security #

Employer

Occupation

No. of years employed

Spouse's Name

Sex

Relationship to Patient

Social Security #

Birthdate

Spouse's Employer

Occupation

No. of years employed

Work Phone

Cell Phone

Is there an additional responsible party for this account?*

Yes
No

Relationship to Patient*

Name

First Middle Last

Address

Street Address City State ZIP Code

Email

Marital Status

Have you been at this address longer than 3 years?

Yes
No

Previous Address

Street Address City State ZIP Code

Home Phone

Work Phone

Cell Phone

Social Security #

Birthdate

Employer

Occupation

No. of years employed

Dental Insurance Information

Insured's Name

Insured's Birthdate

Social Security #

Insurance Company

Group No.

Phone

Insurance Co. Address

Insured's Employer

Subscriber/Employee ID #

Do you have dual coverage?*

Yes
No

IF YES:

Insured's Name

Insured's Birthdate

Social Security #

Insurance Company

Group No.

Phone

Insurance Co. Address

Insured's Employer

Subscriber/Employee ID #

Emergency Information

Name of nearest relative not living with you*

Relationship*

Cell or Phone*

Complete Address*

What are the main concerns that you would like orthodontics to address?

Please describe concerns*

Has the patient ever been evaluated for or had orthodontic treatment before?*

Yes
No

Have there been any injuries to the face, mouth, teeth or chin?*

Yes
No

How does the patient feel about wearing orthodontic appliances?

Have adenoids or tonsils been removed?*

Yes
No

Has the patient been informed of any missing or extra permanent teeth?*

Yes
No

Has the patient ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?*

Yes
No

Does the patient brush his/her teeth daily?*

Yes
No

Floss his/her teeth daily?*

Yes
No

Patient's Dentist*

Phone

Date of Last Visit

Patient's Physician*

Phone

Is the patient currently under the care of a physician?*

Yes
No

If patient is a minor, has puberty begun?*

Yes
No

If yes, when?

Please describe the patient's current physical health*

Good
Fair
Poor

Do you take or have you taken an osteoporosis medication?*

Yes
No

Please list all drugs that the patient is currently taking

Please list all allergies (drugs, foods, other)

Has the patient ever had any of the following medical problems?

Abnormal Bleeding*

Yes
No

ADD/ADHD*

Yes
No

Sleep Apnea*

Yes
No

Allergy to Latex/Metals*

Yes
No

Allergy to Plastic*

Yes
No

Any Hospital Stays*

Yes
No

Any Operations*

Yes
No

Asthma*

Yes
No

Cancer*

Yes
No

Congenital Heart Defect*

Yes
No

Convulsions/Epilepsy*

Yes
No

Diabetes*

Yes
No

Handicaps/Disabilities*

Yes
No

Hearing Impairment*

Yes
No

Heart Murmur*

Yes
No

Hemophilia*

Yes
No

Hepatitis*

Yes
No

HIV+/AIDS*

Yes
No

Kidney/Liver Problems*

Yes
No

Psychological Counseling*

Yes
No

Rheumatic/Scarlet Fever*

Yes
No

Tuberculosis (TB)*

Yes
No

Please discuss any medical problems that the patient has had

Does/Has the patient have/had any of the following habits?

Chew/Smoke Tobacco*

Yes
No

Clenching/Grinding Teeth*

Yes
No

Lip Sucking/Biting*

Yes
No

Mouth Breather*

Yes
No

Nail Biting*

Yes
No

Nursing Bottle Habits*

Yes
No

Speech Problems*

Yes
No

Thumb/Finger Sucking*

Yes
No

Tongue Thrust*

Yes
No

Signatures

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in the patient's medical status. I authorize the dental staff to perform the necessary dental services I/my child may need.

This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use services of one or more credit reporting agencies.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.

I understand that at the time of my office visit, my physical signature will be required to confirm the acknowledgements above.

Signature

Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

Please check your form to make sure it is complete and press the submit button when you are done. You will see a confirmation page when your form has been successfully submitted. Thank you!