Online Forms – Adam Dental Care

Patient's First Name *

Patient's Last Name *

Nickname

Patient's Address

City

State

Zip

Gender

Race

Home Phone

Cell Phone

Date of birth

Age

School/Employer

Grade/Position

Work Phone

Email *

How did you hear about our office

Family members treated in our office

Reason for Consultation

Previous Dentist

Date of last cleaning

Has the patient been examined by an orthodontist before?YesNo

Guardian's First Name

Guardian's Last Name

Home Phone

Cell Phone

Address

City

State

Zip

Employer

Work Phone

Date of birth

Social Security Number

Guardian's E-Mail

Company Name

Phone

Subscriber/Member ID

Is there a second guardian and / or additional insurance to add?YesNo

Guardian's First Name

Guardian's Last Name

Home Phone

Cell Phone

Address

City

State

Zip

Employer

Work Phone

Date of birth

Social Security Number

Guardian's E-Mail

Company Name

Phone

Subscriber/Member ID

Does the patient tend to be a mouthbreather?YesNo

Does the patient snore at night?YesNo

Does the patient seem rested in the morning?YesNo

Is the patient often sleepy during the day?YesNo

Has the patient seen an Ear, Nose & Throat Specialist?YesNo

Is the patient using a sleep apnea device?YesNo

Do your gums bleed when you brush?YesNo

Is the patient seeing any other dental specialists?YesNo

Any dental restorations needing to be completed?YesNo

Have there ever been any injuries to the face, mouth or chin?YesNo

Have you ever lost or chipped any teeth?YesNo

Do you have any pain or soreness around your face, neck or back?YesNo

Is any part of your mouth sensitive to temperature or pressure?YesNo

Is the patient currently pregnant?YesNo

Have adenoids been removed?YesNo

Have tonsils been removed?YesNo

Currently taking any medications?YesNo

Are antibiotics necessary prior to treatment?YesNo

Allergies?YesNo

Any diseases or problems not mentioned above?YesNo

If yes to any of the above, please provide details (medications, allergies, other conditions)

Typed Name/Signature *

Relationship to Patient *

Date *

If someone other than the parent(s) or guardian(s) listed above will be bringing the patient to appointments, please list here

Consent *

By submitting this form I agree to the above mentioned consent statement