New Patient Registration Form - New Patient Registration Form

Patient Information


Responsible Party Information

Marital Status:
Rent or Own:

Orthodontic Insurance Information

Do you have dual coverage?
If yes, please provide the following information:

Emergency Contact Information

I understand that where appropriate credit bureau reports will be obtained.

For staff use only: Reviewed by (date & initial):_______________________

Medical & Dental History

Please check all of the following conditions for which you have been diagnosed or treated:
Has there been any past injury to the face or teeth?
Is there any difficulty with speech?
Is it often difficult to breathe through your nose?
Are you aware of any missing or extra permanent teeth?
Do your gums ever bleed?
Do you have frequent headaches?
Does the jaw joint ever click or pop?
Does the jaw joint ever "catch" or feel restricted in its motion?
Does the jaw joint or jaw get sore or achy when chewing?
Do you grind or clench teeth?
Has there been any oral habits, such as thumb or finger sucking, or tongue thrusting?


I hereby certify that the information given is accurate and complete tothe best of my knowledge and I agree to inform the office immediately of any health status changes. I authorize the exposure of diagnostic x-rays when Gordon and DeSantis Orthodontics, LLC. determine it is indicated.

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Gordon & DeSantis Orthodontics

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