Inglemanparrish.com

Please complete this form and bring it to your first appointment!
Ingleman Parrish Orthodontics Adult Exam
260.447.2568 or 800.829.2568


Patient Name_______________________________________________ Birthdate_____________________ Age________________
Nickname_______________________ Sex:Male_______ Female_______ Social Security #___________-_________-____________ Address ___________________________________________ City______________________ State_________ ZIP_______________ School___________________________________ Grade____________ Home Phone # (_________)-__________-_______________ Mother______________________________ Father_____________________________ Guardian____________________________ General Dentist_____________________________________ E-mail address_____________________________________________ Whom may we thank for referring you?___________________________________________________________________________ Hobbies/Sports_______________________________________________________________________________________________
Responsible Party Name______________________________________________ Marital Status_____________________________
Residence___________________________________________________________________________________________________
How long at this address?_______________________ ______________ Home Phone # (_________)-__________-_______________ Previous Address (if less than 3 years) _________________________________________________________________ ___________ Social Security #_________-________-__________ Birthdate____________________ Relationship to patient__________________ Employer_____________________________________________ Occupation_____________________________________________ No. of Years employed_____ Work # (________)-_________-___________ ext______ Cell# (________)-_________-____________ Spouse’s name_____________________________________________ Social Security #_________-________-__________ Birthdate____________________ Relationship to patient__________________ Employer_____________________________________________ Occupation_____________________________________________ No. of Years employed_____ Work # (________)-_________-___________ ext______ Cell# (________)-_________-____________ Names and Ages of other children in family_________________________________________________________________________ Primary Orthodontic Insurance Secondary Orthodontic Insurance
Insurance Company Name _____________________________ Insurance Company Name ______________________________ Address ____________________________________________ Address _____________________________________________ Group # (Plan, Local, Policy #)___________________________ Group # (Plan, Local, Policy #)____________________________ Phone # (_________)-____________-________________ Phone # (_________)-____________-________________
Policy Owner’s Name __________________________________ Policy Owner’s Name __________________________________ Relationship to Patient_________________________________ Relationship to Patient_________________________________ Social Security #__________-__________-____________ Social Security #__________-__________-____________ Policy Owner’s Employer ______________________________ Policy Owner’s Employer ________________________________ Office use only Office use only
Date cal ed_______/__________/__________ Pre-est__________________ Date cal ed_______/__________/__________ Pre-est______________________ Lifetime Max_____________________ Pays @______________% Lifetime Max_____________________ Pays @______________% Deductible______________________ Amt used_______________ Deductible______________________ Amt used_______________ Reason for Consultation: _______________________________________________________________________________________

MEDICAL HISTORY
Do you have any history of major illness? Yes No Please describe:_______________________________________________________________________________________________ Check any of the following for which the patient has been treated: Diabetes _____ Kidney Problems ______ Fainting or Dizziness ______ Anemia _____ Nervous Disorder ______ Heart Trouble ______ Epilepsy _____ AIDS ______ Rheumatic Fever ______ Asthma _____ Hepatitis ______ Bone Disorders ______ Liver Problems _____ Endocrine Problems ______ Have the Tonsils and Adenoids been removed? Yes No If yes, what age?____________ Please list any drugs or medications now being taken and reasons______________________________________________________ ____________________________________________________________________________________________________________ List any allergies or drug senstitivity:______________________________________________________________________________ Have you ever taken a bisphosphonate or anything else for bone loss? Yes No (Examples include Actinol, Aredia, Boniva, Didronel, Fosamax, Skelid, Zometa) DENTAL HISTORY
Has there been any injury to the face, mouth, or teeth? Yes No Has the patient ever sucked a thumb or fingers? Yes No Does the patient have any speech problems? Yes No Have you been informed of any missing or extra permanent teeth? Yes No Have you consulted another orthodontist? Yes No Have you received full or partial orthodontic treatment in another office? Yes No Please explain:________________________________________________________________________________________________ Are you aware that 80% of appointments will infringe on school time? Yes No Has anyone in the family had braces or received any orthodontic treatment? Yes No In our office?_______ Names:______________________________________________________________________________________________________ Would you consider surgical treatment if necessary? Yes No Please classify the patient’s current desire for improved dental appearance: Excited______ Average______ Casual______ Objects_______ Emergency Contact Information
Name of nearest relative not living with you________________________________________________________________________ Phone # (_________)-__________-_______________ A credit report will be obtained for our interest free payment plan

Source: http://www.inglemanparrish.com/docs/new-patient-form-adult.pdf