Registration Form for Child or Adult Patients

* Patient’s primary address:

* City, state and zip code:

* Phone: How is the best way to contact the patient or responsible party during daytime hours?
 (include area code and extension):

Who is the patient’s Responsible Party:
  Mother   Father   Self   Other

Name of other Responsible Party:   

* Patient’s Email address (or Responsible Party if Patient is under 18 years of age):

Have any other family members received orthodontic treatment? Please name the person:

Who may we thank for referring you or your child:

Patient Current Dentist/Physician Information:

Dentist address, city, state and zip code:

Physician address, city, state and zip code:

Orthodontic Insurance

Does your insurance have orthodontic coverage?     Yes    No

If yes, please complete the following:

Primary Insurance Company address, city, state and zip code:

Secondary Insurance Company phone number:

Secondary Insurance Company address, city, state and zip code:

Secondary Insurance Company phone number:

• I affirm that the information given is correct to the best of my knowledge. It will be held in the strictest of confidence and it is my responsibility to inform this office of any changes.
• Insurance claims will be submitted by Dr. Walton’s office and all insurance payments will be made to Dr. Walton. I understand that I will be responsible for all remaining orthodontic treatment costs not covered by insurance.
• I authorize release of any information relating to this claim to the insurance carrier.

Do you agree?  Yes   No  

* Please write (sign) your full name 

Patient Health and Dental Information:

Is the patient in good health?
   Yes      No

Please check all that apply for which the patient has been treated:

   AIDS
   Anemia
   Arthritis
   Asthma
   Bloody Cough
   Diabetes
   Endocrine Problems
   Epilepsy
   Fainting/Dizziness
   Heart Murmur
   Heart Trouble
   Hepatitis
   Kidney Disease
   Nervous Disorder
   Night Sweats
   Pneumonia
   Prolonged Bleeding
   Prolonged Coughing
   Rheumatic Fever
   Tuberculosis
   None of the above

Other treatment, describe below:

List any allergies or drug sensitivities:

Drugs or medications which the patient is currently taking:

Enter any other problems not listed:

Any injuries to teeth, mouth, or jaws?
 Yes      No

Do this patient require antibiotics before teeth cleaning or other dental appointments?
 Yes      No

Does the patient's lower jaw ever click or get sore?
 Yes      No

If yes, please answer the following:

If click, when?

If sore, when? (Morning, after eating, etc.)

How often does the patient have trouble opening
wide?

Has the patient ever been informed of having any missing or extra permanent teeth?
  Yes     No

Please describe any previous orthodontic treatment:

Any other dental problems or oral habits (thumb sucking, etc.) that we should know about? Enter them here:

What specific concerns do you have regarding the patient's teeth and how they look or function?