New Patient Forms

* required field

Todays Date

Patient Name *

Date of Birth *

Age

Sex * Male Female

Spouse Name

School

Grade

Home Address (home/city/state/zip) *

Primary Phone *

Email *

Patients Physician *

Patients Dentist *

Referred by

Patients favorite activies/hobbies

Mother/Spouse

Name

Address (if different from child)

Home Phone

Cell Phone

Work Phone

Father/Spouse

Spouse Address (if different from child)

Spouse Home Phone

Spouse Cell Phone

Spouse Work Phone

Primary Insurance Co.

Insurance Co. Phone

Group #

Policy #

Subscribers Name

Subscribers Date of Birth

Soc.Sec. #

Subscribers Employer

Secondary Insurance Co.

2nd Insurance Co. Phone

2nd Group #

2nd Policy #

2nd Subscribers Name

2nd Subscribers Date of Birth

2nd Subscribers Soc.Sec. #

2nd Subscribers Employer

Medical History

Is the patient in good health? Yes No
List medications patient is currently taking *

Is patient taking any medication for bone metabolism/parathyroidism? (Bisphosphonates, etc.) * Yes No

List any allergies patient has to drugs, materials, or foods *

Does patient have latex sensitivity? * Yes No

Check if patient has any history of the following

If yes to any of the above, please describe

Dental Health History

Has patient had head or facial injuries? * Yes No

Does patient have a history of any of the following

Mouth breathing Tonsils and/or adenoid removed Speech problems

Has patient ever had a thumb/finger sucking habit? * Yes No

If yes, is the habit currently active? Yes No

Is patient currently experiencing any of the following?

What do you think is patients main orthodontic problem?

Have any family members had orthodontic treatment? Yes No

With Dr. Charchut? Yes No

Any additional comments that may be helpful

New Patient Forms

New Patient Information

Parent Information

Dental Insurance Information

Medical History

Dental Health History