Boschken Orthodontics Forms, Los Altos CA

Adult Patient Form

We would like to welcome you to our office. In an effort to provide the best service possible, we ask you to fill out this form as completely as possible. Thank you for your cooperation.

This is a secure form.

Patient Information

Patient's Name:

First

Middle

Last

Nickname (if preferred):

Male Female

Home Phone:

Cell Phone:

Patient's Birthdate:
Social Security #:
Email:

Home Address:

Employer:
Employer Address:
Occupation:
How Long?
General Dentist:

How did you hear about our office?
Have we treated another member of your family?	YES NO If YES, Name:
What are the main concerns that you would like orthodontics to accomplish?
Have you visited an orthodontist before?	YES NO If YES, for what reason?:
Anything you would like to discuss with the doctor in private?	YES NO

Insurance Information

Marital Status:

Single Married Widowed
Divorced Separated Domestic Partner

Primary

Insurance Co. Name:
Insurance Co. Phone:
Insurance Co. Address:
Group or Plan:
Insured's Name
Insured's Birthdate:
Relationship:
Insured's SS#:
Insured's Employer:
Employer's Address:

Secondary

Insurance Co. Name:
Insurance Co. Phone:
Insurance Co. Address:
Group or Plan:
Insured's Name
Insured's Birthdate:
Relationship:
Insured's SS#:
Insured's Employer:
Employer's Address:

Dental and Medical History

Are you currently under the care of a physician?	YES NO If YES, for what reason?:
Physician:
Phone#:
History of major illness?	YES NO If YES, please describe:
Any sensitivities or allergies?	YES NO If YES, please describe:
Currently taking any medications?	YES NO If YES, please describe: Amount/Dose:

Have you been treated for any of the following?

Arthritis
Asthma
Blood Disorder
Cancer
Diabetes

Epilepsy
Heart Condition
Nervous Disorder
Tuberculosis
High Blood Pressure

Do you require antibiotics before dental treatment?	YES NO If YES, explain:
Have there been injuries to your face, mouth or chin?	YES NO
Have you ever had pain/tenderness in your jaw joint (TMJ/TMD)?	YES NO

Do/Did you have any of the following habits?

Grinding Teeth
Chronic Mouth Breathing
Finger/Thumb Sucking

Speech Problems
Tongue Thrusting
Chewing/Eating Problems

(required) - I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child’s medical status.

I hereby authorize release of any information related to insurance claim. I consent to examination by the doctor and I authorize payment of any insurance benefits to the office.