New Patient Welcome Form | Go Clear Orthodontics

WELCOME TO OUR PRACTICE!

To assist us in providing the most amazing and complete service, please provide the following information and health history.
Patient First Name: *
Patient Last Name: *
Preferred Name:
We will call you by this name!
Date Of Birth: *

Month Day Year
Responsible Party First/Last Name:
If different than above
Responsible Party's SS #: *
Address: *
City: *
State: *
ZIP: *
Mobile #: *
Home #:
Work #:
E-mail *
Employer:
Current Dentist: *
N/A if you don't have one
What is Your Primary Concern? *
Whom should we thank for referring you? *
Describe Your Attitude Towards Orthodontics (Select One): *

Transform My Smile and Do It Yesterday! I’m Anxious About the Process, But I Know How Much It Will Benefit Me I Have Some Concerns and I Just Want to Find Out More Information
PARENT INFORMATION (IF MINOR PATIENT)
Responsible Party’s First/Last Name
Relationship to Patient:
Date of Birth:

Month Day Year
SS#:
Employer:
Mobile #: *
E-mail:
PRIMARY DENTAL INSURANCE
Orthodontic Coverage? *

Yes No
Policy Holder’s Name: *
Policy Holder's SS# or ID#: *
Policy Holder's Employer: *
Group #: *
Insurance Co. Name: *
Insurance Co. Phone #: *
Insurance Co. Address: *
Policy Holder’s DOB *

Month Day Year
SECONDARY DENTAL INSURANCE
Orthodontic Coverage? *

Yes No
Policy Holder’s Name: *
Policy Holder’s SS# or ID#: *
Policy Holder’s Employer: *
Group #: *
Insurance Co. Name: *
Insurance Co. Phone #: *
Insurance Co. Address: *
Policy Holder’s Date Of Birth: *

Month Day Year
Go Clear Orthodontics

259 Textile Way ° Suite 103 ° Fort Mill, SC 29715

Phone 803-650-3068

www.goclearorthodontics.com

MEDICAL HISTORY *

	Yes	No	Unsure
ADHD
Asthma
Arthritis/Joint Issues
Bleeding/Clotting Disorders
Cancer/Radiation
Diabetes
Epilepsy/Seizures
Heart Condition
Hepatitis or HIV
Kidney or Liver Disease
Pregnancy (No X-Rays)
Psychiatric Disorders
Sleep Apnea
Thyroid Issues
Tonsils/Adenoids Removed

Currently Under Physician’s Care? *

Yes No
Physician Name:
Reason
Comments
Describe any medical conditions not listed:
Please list any current prescriptions/medications: *
N/A if no medications
Known Allergies: (check all that apply)

Latex Nickel Medications

DENTAL HISTORY *

	Yes	No	Unsure
Visited your dentist within the last year?
Any history of orthodontic treatment?
Any missing or extra teeth?
Any gum recession or bone loss?
Any tooth-related pain or sensitivity?
Any jaw-relaated pain or sensitivity?
Any difficulty chewing or biting?
Frequent headaches? (more than 1/week)
Any difficulty breathing through the nose?
Any fatigue/excessive daytime sleepiness?
Any oral habits? (nail biting, thumb sucking, tongue trusting, etc.)
Ever had scaling and root planing? ("deep cleaning")
Ever had a tooth extracted?
Ever had a filling?
Any dental/facial trauma or surgeries?

Currently Under Dentist's Care? *

Yes No
Dentist Name:
Describe any dental conditions not listed:
If there was only ONE THING you could change about your smile, what would it be? *
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
Initials *

Clear
I understand that I am responsible for payment of services rendered. I understand that I am responsible for paying any costs that my insurance will not cover. I also understand that insurance pays over my treatment time, and may not pay in full up front. If I change or lose my insurance for any reason during my treatment, I will be responsible for any charges remaining on the account.
Initials *

Clear
Should be Empty:

WELCOME TO OUR PRACTICE!