New Patient Form

Patient's Name *

Age *

Birthdate *

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone *

Gender *

Male
Female

Have you had previous orthodontic consultations? *

Yes
No

Previous orthodontic treatment? *

Yes
No

If so, when/where?

Doctor's Name

What is the primary reason you are seeking this orthodontic evaluation? *

Who may we thank for referring you to Feldman Orthodontics?

RESPONSIBLE PARTY INFORMATION

(If patient is under 18)

Name

Relation to Patient

Marital Status

S
M
W
D

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Email

Birthdate

Employer

# Yrs. Employed?

Occupation

Work Phone

Spouse's Name (if applicable)

Spouse's Phone

Spouse's Employer

Spouse's Occupation

DENTAL INFORMATION

Patient's Dentist *

Patient's Last Dental Visit *

Has patient had facial or dental injury due to accidents? *

Has the patient ever experienced pain, clicking, or popping in his/her jaw joints?

Yes
No

Pain

Right
Left

Clicking

Right
Left

Popping

Right
Left

Earaches

Right
Left

MEDICAL INFORMATION

Patient's Overall Health *

Excellent
Good
Poor

Is patient currently under the care of a doctor, other than for routine examinations? *

Yes
No

If yes, for what?

Is patient currently taking any medication? *

Yes
No

If yes, for what?

Are you allergic to:

Metals
Latex

Please discuss any serious medical conditions the patient has/had

INSURANCE INFORMATION

Policy Holder's Name

Social Security #

Birthdate

Name of Insurance Co.

Phone #

Address of Insurance Co.

Address Line 1

Address Line 2

City

State

Zip Code

Policy #

Group #

Employer

Privacy Policy

I have read and accept the Privacy Policy

New Patient Form

RESPONSIBLE PARTY INFORMATION

DENTAL INFORMATION

MEDICAL INFORMATION

INSURANCE INFORMATION

New Iberia

Youngsville

New Iberia

Youngsville

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