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Lansing 517-321-0238
St. Johns 989-224-2404
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Steven W. Charchut, D.M.D., M.S.
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Home
Office
Meet Dr. Charchut
Meet Our Staff
Office Tour
Office Policies
Financial
Map and Directions
Patient
First Visit
New Patient Forms
Common Problems
FAQ
Oral Hygiene
Foods to Avoid
Emergencies
Treatment
Early Treatment
Adult Treatment
Types of Braces
Retention
Clear Aligners
Orthognathic Surgery
Misc.
Contests & Events
Doctor Referral
Related Links
Glossary
Contact Us
Home
Office
Meet Dr. Charchut
Meet Our Staff
Office Tour
Office Policies
Financial
Map and Directions
Patient
First Visit
New Patient Forms
Common Problems
FAQ
Oral Hygiene
Foods to Avoid
Emergencies
Treatment
Early Treatment
Adult Treatment
Types of Braces
Retention
Clear Aligners
Orthognathic Surgery
Misc.
Contests & Events
Doctor Referral
Related Links
Glossary
Contact Us
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New Patient Forms
Adult Registration Form - Ortho
*
required field
New Patient Information
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
Parent Information
Mother/Spouse
Mother
Step-Mother
Guardian
Other
Name
Address (if different from child)
Home Phone
Cell Phone
Work Phone
Father/Spouse
Father
Step-Father
Guardian
Other
Spouse Address (if different from child)
Spouse Home Phone
Spouse Cell Phone
Spouse Work Phone
Marital Status
Single
Married
Divorced
Separated
Dental Insurance Information
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
Asthma
Blood/bleeding disorders
Diabetes
Eating disorders
Heart disease / murmur
Hepatitis
Epilepsy
Other
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?
Clenching/grinding teeth
Muscle soreness in head/neck
Frequent headaches
Jaw joint (TMJ) clicking/popping
Jaw joint (TMJ) soreness
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
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