Adult Form

Adult Registration Form - Ortho

Patient Information

Gender:
Phone Type
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Spouse / Partner Information

Marital Status:
Phone Type:
Phone Type:

Emergency Contact Information

Insurance Information

Primary Insurance

Secondary Insurance

Dental History

How did you hear about our practice?
Have you visited an orthodontist before?
Have your tonsils or adenoids been removed?
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Do you have any missing or extra permanent teeth?
Have you ever had an injury to (select all that apply):
Do you have speech problems?
Do your gums bleed?
Do you smoke?
Do you like your smile?
Do you currently or have you ever had any of the following habits (check all that apply):

Medical History

Are you currently being treated by a physician?
Do you have any allergies/sensitivities to medications or latex?
Are you currently taking any prescription or over-the-counter medications?
Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Have you ever had a blood transfusion?
(Women) Are you pregnant?
Nursing?
Taking birth control pills?
Check if you have ever had any of the following:

Authorization

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 of confidence and it is my responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.



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Bay Meadows Orthodontics

  • Bay Meadows Orthodontics - 3455 Pacific Blvd., Suite 1, San Mateo, CA 94403 Phone: 650-638-1500 Fax: 650-638-1511
  • Satellite Office - 133 Kearny St., #301, San Francisco, CA 94108 Phone: 415-989-3648 Fax: 650-638-1511
  • Satellite Office - 2817 San Bruno Ave., San Francisco, CA 94134 Phone: 415-656-2868 Fax: 650-638-1511
  • Satellite Office - 15931 Hesperian Blvd., San Lorenzo, CA 94580 Phone: 510-481-5492 Fax: 650-638-1511

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