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:

Primary 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:

* The patient's health history is a required field.
If you do not wish to submit the information electronically, forms are available to fill out in the office at your appointment.

Is the patient in good health?
    Yes           No

Please check yes or no for any condition for which the patient has been treated:
 

AIDS    Yes     No Anemia    Yes     No Arthritis    Yes     No Asthma    Yes     No Bloody Cough    Yes     No Diabetes    Yes     No Endocrine Problems    Yes     No Epilepsy    Yes     No Fainting/Dizziness    Yes     No Heart Murmur    Yes     No Heart Trouble    Yes     No Hepatitis    Yes     No Juvenile Rheumatoid Arthritis    Yes     No Kidney Disease    Yes     No Nervous Disorder    Yes     No Night Sweats    Yes     No Pneumonia    Yes     No Prolonged Bleeding    Yes     No Prolonged Coughing    Yes     No Rheumatic Fever    Yes     No Tuberculosis   Yes      No

 

Does the patient require antibiotics before teeth cleaning or other dental appointments?
  Yes            No

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

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?