New Patient Form 

Welcome to our practice. To best serve you and make your first appointment as efficient as possible, we ask that you fill out all of the following information as completely as possible. We are looking forward to meeting you!!

Patient Name
Birth Date

       
 OK to leave message?
 
 OK to leave message?

We have found that the best way to stay in contact is through texting – You can text us at any time using our office number (865-522-0121)

 May we text information about patient appointments/treatment at this number?
 
 May we email information about patient appointments/treatment at this address?
     

 Primary Insurance
Phone Number
Group #
Member ID
Policy Holder's Name
Relation
Policy Holder SSN
Policy Holder Birth Date              
Policy Holder Birth Date      

Dentist Name
Have you visited an orthodontist before?
 Yes
 No

Please rate the patient's oral health:
 Good
 Fair
 Poor

Do you have regular dental check-ups?
 Yes
 No

When was the last check-up?

Do you clinch/grind your teeth?
 Yes
 No

Do you have pain/tenderness/clicking in your jaw joint (TMJ), frequent headaches?
 Yes
 No

Do you have any of the following habits? (Select all that apply)
 Thumb Sucking
 Lip Biting
 Speech Difficulty
 Nail Biting
 Mouth Breathing
     

Please rate your overall health:
 Good
 Fair
 Poor

Are you currently being treated by a physician?
 Yes
 No

Reason
Physician Name:
Phone Number
Are you taking any prescription or over-the-counter drugs? If yes, please list:
Are you allergic to any drugs or other substances (including heavy metals or latex)? If yes, please list:
Have you ever experienced the following medical conditions? (Check any that apply)
 Abnormal Bleeding
 Aids
 Anemia
 Asthma
 Cancer
 Chicken Pox
 Congenital Heart Defect
 Convulsions
 Diabetes
 Epilepsy
 Heart Murmur
 Hemophilia
 Hepatitis
 High Blood Pressure
 HIV +
 Kidney Problems
 Low Blood Pressure
 Rheumatic Fever
 Skin Rashes
 Tuberculosis (TB)
 Tonsilitis

Are you currently Pregnant or Nursing?
 Yes
 No

Are there any other medical conditions we should be aware of? If yes, please explain:
Has your physician told you that you need to be premedicated with an antibiotic before dental procedures? If yes, what is the medical condition and what is the antibiotic?

I understand that the information provided 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 payments of any benefits to the office of Langford Orthodontics. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY INSURANCE (FOR ANY REASON).

  I give Langford Orthodontics permission to use my photos and videos for marketing and social media advertising.

Signature of Patient/Responsible Party:
Date:

** We have found that the best way to communicate with our patients is through email or texting. You may text us at any time by using our office number (865-522-0121). We are often able to communicate with you more efficiently through texting – without interfering with your day.

May we text information about patient appointments, treatment, and financial status to the Cell Phone number provided?
    Date:
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