New Patient Form

Step 1 of 5 – General Information

20%

For office visit at:

Patient's Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Date of Birth

Month

Day

Year

SSN

If patient is a minor, parent or guardian full name

First Last

Sibling(s) – Names and ages

Whom may we thank for referring you to our office?

First Last

Name of General Dentist

Responsible Party Name

First Last

Relationship to patient

Address

Street Address Address Line 2 City State ZIP Code

Mobile Phone

Work Phone

SSN

Marital Status

Date of Birth

Month

Day

Year

Employer

Occupation

Spouse's Name

First Last

Employer

Occupation

Years Employed

SSN

Date of Birth

Month

Day

Year

Phone

Insured's Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Subscriber's Identification Number

Insurance Company Name

Insurance Company Address

Group Number

Insurance Phone Number

Dual Coverage?

Yes

If dual coverage, name of covered person?

Insured's Employer

Release of information authorization

I authorize the release of information for insurance purposes

Patient's Name

First Last

Nicknames and/or Aliases

Has the patient recently (within past year) received treatment from a medical professional? Explain.

Please list any medications being taken or none if not taking any

Have you ever had any major operations?

Please list any operations

Please list all allergies

Has the patient ever received a severe blow to the teeth or jaws?

Yes

Has the patient been to a dentist in the last 12 months?

Yes

Does the patient constantly have sore or bleeding gums?

Yes

Have the patient's teeth been removed?

Yes

Which teeth have been removed?

Has the patient ever sucked fingers, thumbs, lips or tongue? If yes, does he/she still do it or what age did he/she stop?

Does the patient play a wind musical instrument? If yes, what kind?

Who first noticed the need for orthodontic treatment?

Has any other member of the family had orthodontic treatment? If so, who?

Has the patient ever had "braces" before?

Yes

Does any member of the family or close relative have similar arrangement of teeth or similar appearance of jaws? If so, who?

Is the patient dissatisfied with the appearance of their teeth? If so, please describe what the patient would like to have fixed or look better.

If you are completing this form for a minor, are you concerned about the appearance of their teeth? If so, please describe what you would like to have fixed.

Is the patient dissatisfied with the appearance of their facial features (nose, chin, jaw, etc.)? If so, how?

Has the patient ever been teased about the appearance of their teeth and/or face?

Please give us any other information that you feel may be pertinent to the patient's situation in regards to corrective dental procedures

Acknowledgements

I understand that Clear Choice Orthodontic Associates will make every attempt to schedule appointments for convenience, but under certain circumstances, orthodontic appointments may infringe on school and/or work schedules.

I understand that records are stored electronically and that an electronic copy shall be considered an original for all purposes.

By law, we are required to provide you with you with our Notice of Privacy Practice. This information is available on our web site located at www.clearchoiceortho.com or upon request on your first visit. This shall also serve as consent to use and/or disclose your protected health information to carry out treatment, payment activities, and health care operations. If you should have any questions regarding this Notice and Consent, you may contact Clear Choice Orthodontics at (281) 587-4900 or email clinical@clearchoiceortho.com

5-STAR-RATED ORTHODONTISTS IN HOUSTON, TX, FRIENDSWOOD, TX, SPRING, TX & KATY, TX

"I have always received first class treatment at Clear Choice Orthodontics. I am always impressed by the professional staff and friendliness. I would highly recommend them to anyone looking for orthodontic work! I love them!"

Dawn A.

“I absolutely loveeeeee the staff at Clear Choice. My daughter’s father is a patient there, and recommended that our daughter go for her braces. They are nice, clean, efficient, and fast!!! Almost makes me wanna get braces for fun!”

Marcie K.

“The staff and the Dr. were very helpful. They made sure they answered all of our questions and more. This was my daughters first visit and I am very pleased. Thanks again!!”

Wendy M.

*The reviews listed are from actual patients of Clear Choice Orthodontic Associates. Individual results may vary. Reviews are not claimed to represent results for everyone.