New Patient

Walnut Grove Orthodontist

New Patient Form

New Patient
Dental Insurance

Plan #1 (Primary)

Plan #2 (Secondary)

Dental History

Have you had regular dental visits in the past?
Do you have clicking/popping sound from your jaw?
Are you currently having any dental pain?
Are you aware of any sores or lumps in your mouth?
Do your gums bleed when you brush/floss?
Are you aware of clenching or grinding your teeth?
Have you ever had orthodontic treatment before?
Have you ever been treated for periodontal (gum) disease

Medical History

Have you had any of the following?
Have you been diagnosed with a spectrum disorder?
Have you ever been a patient in hospital or under the care of a physician during the past 2 years?
Have you taken any kind of drugs or medicine in the past 2 years?
Are you allergic to latex, penicillin or any other drugs or medications?
Do you ever have chest pains?
Have you ever experienced unexplained shortness of breath?
Have you ever experienced excessive bleeding that required special treatment?
Have you ever had a serious illness?
Are you pregnant now?

Consent of Treatment

  1. I certify that the above information is correct to the best of my knowledge
  2. I authorize the doctor upon consultation and direct consent from patient/parent/guardian to perform diagnostic procedures, treatment and medication in connection with the patients dental needs
  3. I understand the responsibility for payments of dental services, including insurance or otherwise, is due and payable at the time services are rendered and despite any dental insurance. I am ultimately responsible for any fees withheld by the insurance company
Are you a: