New Patient Form New Patient Form PATIENT INFORMATIONName** First Name Middle Name Last Name NicknameAge*Birth Date* Date Format: MM slash DD slash YYYY Sex*MaleFemaleAddress* Address* City* State* Zip* Cell*HomeEmail* SchoolGradeHobbies/SportsEmployerOccupationHow Long?GENERAL INFORMATIONHow did you hear of Heidi Harman Orthodontics?Has the patient had prior orthodontic treatment or exam?Where/When?General DentistPhoneLast VisitChildren/Siblings (Ages)RESPONSIBLE PARTY INFORMATIONMarital StatusSingleMarriedPartneredWidowedDivorcedSeparatedRelationship to Patient Relationship to PatientNameSex*MaleFemaleAddress Address* City* State* Zip* SSNBirth Date Date Format: MM slash DD slash YYYY CellHomeWorkEmail EmployerOccupationIf you have orthodontic insurance coverage for the patientYesNoInsurance Company NameInsurance PhoneID#Group#Relationship to Patient 2Relationship to PatientNameSex*MaleFemaleAddress Address* City* State* Zip* SSNBirth Date Date Format: MM slash DD slash YYYY CellHomeWorkEmail EmployerOccupationIf you have orthodontic insurance coverage for the patientYesNoInsurance Company NameInsurance PhoneID#Group#MEDICAL HISTORYHistory of the following: (Please check all that apply) Blood Disorder ADD/ADHD AIDS Congenital Heart Defect Cancer Hepatitis/HIV High Blood Pressure Arthritis Asthma Joint Replacements Diabetes Kidney Nervous Disorder Epilepsy Tuberculosis Heart Conditions Bone Density History of major illnessIs the patient allergic to LATEX NICKEL/METALS PLASTIC Other Sensitivities / AllergiesCurrent MedicationsDoes the patient require antibiotics before dental treatment?YesNoPuberty?YesNoHas menstruation started?YesNoDENTAL HISTORYHistory of the following: (Please check all that apply) Difficulty Chewing/Eating Clenching Snoring Lip Sucking/Biting Ear Infection Grinding Pacifier (infant) Finger/Thumb Nail Biting Soda/Juice Overconsumption Mouth Breathing Speech Tongue Thrust Sleep Apnea Pain TMJ: Jaw Popping/Locking Mouth Guard Headaches Adenoids or tonsils removed?YesNoMissing or extra permanent teeth?YesNoInjuries to the face, mouth or jaw?YesNoDiscomfort in the jaw (TMJ/TMD)?YesNoDifficulty breathing through nose?YesNoDoes the patient brush their teeth daily?YesNoFloss?YesNoI certify that the above information is correct and that this office will not be held responsible for situations arising out of inadequate information not disclosed. I authorize Heidi Harman Orthodontics to share any and all of this patient's diagnostic records, images, photos, etc. and pertinent information with doctors, dentists, surgeons and insurance companies or any individual or entity necessary by electronic mail to provide and complete care for this patient. I was offered a copy of this office's Notice of Privacy Practices/HIPAA disclosure.Patient/Guardian Signature*Date Date Format: MM slash DD slash YYYY