New Patient Form Adult

New Patient Ortho Form - Adult

* Required Fields

Patient Information

* Gender

* Primary Phone:
Secondary Phone:

Spouse / Partner Information

* Marital Status

* Person(s) OK to release appointment or medically related information to concerning you:

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 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 smoke?
* Do you like your smile?
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 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)?
Have you had any serious illnesses or operations? If yes, describe:
Have you ever had a blood transfusion?
* (Women) Are you pregnant?
Check if you have or have ever had any of the following:

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.



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Lefort Orthodontics

  • Lefort Orthodontics - 2628 Country Club Rd., Lake Charles, LA 70605 Phone: 337-436-3631 Fax: 337-436-3632
  • Lefort Orthodontics - 420 Cypress Street, Sulphur, LA 70663 Phone: 337-528-2215

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