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Drobocky Orthodontics, Oles Drobocky, DMD, MSSSL Certificate Authority
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New Patient Form
Welcome to our orthodontic family. Our goal
is to make your visit pleasant and educational. We strive to teach good oral
care that will enable you to have a beautiful smile that lasts a lifetime.

* Required fields are denoted with an asterisk

Patient Information
*Date

*Patient Last Name
*First Name
*Middle Name
*Street Address

*City

*State
*Zip
*Home Phone
*Birthdate
*Social
Security #

Email

Marital Status
If patient is a minor,
give the parent's or guardian's name
Whom may we thank for
referring you to our office?

Person Responsible For Account
*Last Name

*First Name
*Middle Name
*Street Address

*City
*State

*Zip
Mailing Address
*How long at this
address?
*Home Phone
Work Phone

Previous Address (if less than 3
years)
*Social Security #
*Birthdate
*Relationship to
Patient
Employer

Occupation
No. of years employed
Spouse's Name
Relationship to Patient
Spouse's Employer

Occupation
No. of years employed
Social Security #
Birthdate
Work Phone

Insurance Information
Insured's Name
Social Security #
Insurance Company
Group No.

Phone
Insurance Co. Address
Do you have dual coverage?
Insured's Name

Social Security #
Insurance Company
Group No.

Phone
Insurance Co. Address
Insured's Employer

Emergency Information
*Name of nearest relative
not living with you

*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?

*Have
there been any injuries to the face, mouth, teeth or chin?
List any musical instruments
played

*Have
adenoids or tonsils been removed?
*Has
the patient been informed of any missing or extra permanent teeth?
*HAS
THE PATIENT EVER HAD ANY PAIN/TENDERNESS IN HIS/HER JAW JOINT (TMJ/TMD)?

*Does
the patient brush his/her teeth daily?
Floss
his/her teeth daily?
*Patient's
Physician
Phone

Date of Last Visit
*Is
the patient currently under the care of a physician?
*Please describe the patient's current physical health
Please list all drugs that the patient is currently taking
Please list all drugs that the patient is allergic to

Has the patient ever had any of the following medical
problems?
*Abnormal Bleeding
*Allergies to any Drugs

*Handicaps/Disabilities
*Allergy to
Latex/Metals

*Hearing Impairment
*Allergy to Plastic

*Heart Murmur
*Any Operations

*Hepatitis
*Cancer

*Kidney/Liver Problems
*Congenital Heart
Defect

*Rheumatic/Scarlet Fever
*Tuberculosis (TB)

Please discuss any medical
problems that the patient has had

Does/Has the patient have/had any of the following habits?
*Clenching/Grinding
Teeth
*Lip Sucking/Biting

*Speech Problems
*Nail Biting

*Tongue Thrust

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.

The Parent
or Guardian who accompanies the child is responsible for payment. 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!

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