We are really excited to meet you! How did you hear about us? (Select all that apply)
Google
Facebook
Instagram
Referred by a dentist
Referred by a family member
Referred by a friend
Saw your booth at an event
Saw a printed advertisement
Driving by
Other

If you were referred to our practice, whom may we thank for referring you?

Is there anything specific that you would like to change about the appearance of your smile?

What type of treatment are you interested in?
Comprehensive Treatment - I want everything fixed!
Limited Treatment - I just want my teeth straight; I don't care if my bite is off.

Which METHOD of treatment are you most interested in?
Traditional metal braces
Clear ceramic braces
Clear aligner therapy
"I'm open to whatever Dr. Hemphill recommends is best for my case."

What aspects of treatment are most important to you? (Select all that apply)
Quality - "I want the best final result I can possibly get."
Time/Speed - "I want my teeth straightened as fast as possible."
Cost - "I'm looking for the most affordable option."
Experience - "I want to enjoy the process and have a good experience with my treatment."
Questions - "I have a lot of questions about my teeth, and I want to ask a specialist."

We know your time is valuable. Sometimes our schedule allows for starting treatment the same day as your consultation. If time allows, would you be interested in staying after to save yourself a separate trip in the future?

Full Name

Preferred Name / Nickname

Gender

Date of birth?

Social Security Number

Home Address

City

State

Zip

Cell Phone Number

Email

Employer

Job Title

How long at current job?

Hobbies/Interests

Dentist's name (if able, please also include practice name, phone number, and email)

Approximate (or exact!) date of last dental cleaning and checkup

Have you been evaluated by an orthodontist before?

Have you had orthodontic treatment before?

Have we treated any family members? Please list.

Marital Status

Who will be financially responsible for your account with us?

Responsible Party Information

Name of person financially responsible for account

Billing Address (if different from Home Address)

City

State

Zip

Phone Number (if different from cell phone)

Email Address

Name of person responsible for scheduling appointments

Phone Number (if different from above)

Email Address (if different from above)

Orthodontic Insurance Information

Policy Owner's Name

Policy Owner's Date of Birth

Policy Owner's Relationship to Patient

Insurance Company Name

Insurance Company Address

City

State

Zip

Insurance Company Phone Number

Group # (Plan, Local or Policy #)

ID# or SSN

Policy Owner's Employer

Policy Owner's Employer Address

City

State

Zip

Do you have secondary orthodontic insurance?
If yes, please fill out the following:

Policy Owner's Name

Policy Owner's Date of Birth

Policy Owner's Relationship to Patient

Insurance Company Name

Insurance Company Address

City

State

Zip

Secondary Insurance Company Phone

Group # (Plan, Local or Policy #)

ID# or SSN

Policy Owner's Employer

Policy Owner's Employer Address

City

State

Zip

Are you aware of any other disease, condition, or problem not listed above? (If yes, please describe.)

Have you ever had any hospital stays or operations? (If yes, please describe.)

Have you had tonsils and/or adenoids removed?

Do you smoke or use tobacco?

Are you currently under medical care?

Please describe your overall physical health:

Are you currently taking any medications? (If yes, please list them here.)

Are you allergic to any drugs/latex/metals/plastics or other things? (If yes, please list allergies and type of reaction.)

Do you BRUSH your teeth daily?

Do you FLOSS your teeth daily?

Are you aware of any of the following dental problems?
Trauma/injury to teeth, mouth, jaws, or face
Missing permanent teeth
Extra permanent teeth
Periodontal or "gum" problems
Clicking/popping of the jaw
Jaw discomfort or pain
None of the above

Has a physician or dentist ever recommended that you take antibiotics before a dental appointment?

I certify that the information provided on this form is correct to the best of my knowledge. I understand that it is my responsibility to report any changes.
I agree

Signature:

Adult Patient Form

Responsible Party Information

Orthodontic Insurance Information