New Patient Form - Glovsky Orthodontics

Call or Text (480)892-6200

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Corsa

About Us
New Patients
Treatment
Braces
Contact Us

Today's Date
Date of Birth
Age
Gender
- Male
- Female
Name
Last*
First*
Initial*
Nickname
Address*
City*
State*
Zip*
Home Phone #
Cell Phone #
Work Phone #
Email*
Who may we thank for referring you?
Family members treated in our office:
Name Relationship to Patient
If Patient is a child
Who is with patient today? Relationship to Patient
School
Grade
Patient's Mother*
Phone #*
Employer*
Patient's Father*
Phone #*
Employer*
Patients Guardian
Phone #*
Employer*
Child lives with
- Mom
- Dad
- Both
PRIMARY RESPONSIBLE PARTY INFORMATION
Responsible Party*
DOB*
Relationship to Patient*
Social Security #*
Address (if different)*
City*
State*
Zip*
Employer*
Occupation*
Subscriber ID#*
Group #*
SECONDARY RESPONSIBLE PARTY INFORMATION
Responsible Party*
DOB*
Relationship to Patient*
Social Security #*
Address (if different)*
City*
State*
Zip*
Employer*
Occupation*
Subscriber ID#*
Group #*
PATIENT DENTAL HISTORY
Previous/Present Dentist*
Last Visit*
Check (Yes | No) if you/your child experienced the following:
BAD BREATH*
- YES
- NO
BLEEDING GUMS*
- YES
- NO
JAW CLICKING*
- YES
- NO
SENSITIVITY TO COLD*
- YES
- NO
SENSITIVITY TO HOT*
- YES
- NO
FOOD COLLECTING BETWEEN TEETH*
- YES
- NO
SENSITIVITY TO SWEETS*
- YES
- NO
LOOSE/BROKEN TEETH*
- YES
- NO
GRINDING/CLENCHING TEETH*
- YES
- NO
SENSITIVITY TO SWEETS*
- YES
- NO
LOOSE/BROKEN TEETH*
- YES
- NO
GRINDING/CLENCHING TEETH*
- YES
- NO
SORES IN MOUTH*
- YES
- NO
MOUTH BREATHING*
- YES
- NO
PERIODONTAL TREATMENT*
- YES
- NO
SNORING*
- YES
- NO
NAIL BITING*
- YES
- NO
THUMB/FINGER SUCKING*
- YES
- NO
Any injuries to the mouth or chin?*
- YES
- NO
If YES, please explain:*
Have you/your child ever been evaluated for orthodontic treatment?*
- YES
- NO
Orthodontist:*
MEDICAL HISTORY
Physician*
Phone #*
Any recent illness (or) surgeries*
- YES
- NO
If YES, please describe:*
Are you/your child currently under physician care?*
- YES
- NO
If YES, please describe:*
Do you/does your child still have
Tonsils*
- YES
- NO
Adenoids*
- YES
- NO
Women
Are you pregnant?*
- YES
- NO
Taking birth control?*
- YES
- NO
Circle (Yes | No) whether you/your child have/has/had any of the following:
AIDS/HIV+*
- YES
- NO
HEPATITIS*
- YES
- NO
HIGH BLOOD PRESSURE*
- YES
- NO
DIABETES*
- YES
- NO
KIDNEY DISEASE*
- YES
- NO
HEART MURMUR*
- YES
- NO
LIVER DISEASE*
- YES
- NO
HEMOPHILIA*
- YES
- NO
HEART ATTACK*
- YES
- NO
JAW PAIN*
- YES
- NO
EPILEPSY*
- YES
- NO
CONGENITAL HEART DEFECT*
- YES
- NO
SINUSES*
- YES
- NO
TUBERCULOSIS*
- YES
- NO
DRUG/ALCOHOL ABUSE*
- YES
- NO
COLD SORES*
- YES
- NO
RHEUM FEVER*
- YES
- NO
MITRAL VALVE PROLAPSE*
- YES
- NO
AUTOIMMUNE DISEASE*
- YES
- NO
CANCER*
- YES
- NO
ARTHRITIS*
- YES
- NO
Are you/your child taking any medication for your bones?*
- YES
- NO
If YES, please list:*
Are you/your child currently taking any medications?*
- YES
- NO
If YES, please list:*
Do you/your child have any drug allergies?*
- YES
- NO
If YES, please list:*
ALLERGIC TO LATEX?*
- YES
- NO
I understand the information that I have given is correct to the best of my knowledge and that it will be held in the strictest of confidence. It is my responsibility to inform this office of any changes in my/my child’s medical status. I also authorize the orthodontic staff to perform the necessary orthodontic services I/my child may need.

I have also read, understand and have been offered a copy of the HIPAA consent form.
Signature*
Date*

Glovsky Orthodontics

754 S. Val Vista Dr., Suite 107
Gilbert, AZ 85296

Office Hours

Mon – Wed: 8 a.m. – 5 p.m
Thurs: 9 a.m – 4 p.m

Phone: (480) 892-6200
Fax: (480) 632-0884

Name	Relationship to Patient

Who is with patient today?	Relationship to Patient

PRIMARY RESPONSIBLE PARTY INFORMATION

SECONDARY RESPONSIBLE PARTY INFORMATION

PATIENT DENTAL HISTORY

Glovsky Orthodontics

Office Hours