Adult Patient Registration

Patient Information

* Patient Name: (Required)

I preffered to be called:

Gender: Male Female

Birth Date:

Age:

Home Address:

City:

State:

Zip:

Home Phone Number:

E-mail:

Social Security Number:

Employer's Name:

Occupation:

No. Years With Present Employer:

Work Phone Number:

Cell Phone Number:

Cell Service Provider:

Your General Dentist

Name:

Last Visit:

Who may we thank for referring you to our practice?

Other Referrals:

Other Family Members Seen By Us:

Spouse / Partner Information

Spouse/Partner's Name:

Employer's Name:

Occupation:

No. years with present employer:

Cell/Work Phone Number:

Social Security Number:

Responsible Party and Insurance Information

Name:

Address:

Own Rent

How Long At This Address:

Home/Cell #:

Previous Address if less than 3 years:

Employer:

Occupation:

No. Years Employed:

Primary Orthodontic Insurance

Orthodontic Coverage? Yes No

Primary Insurance Company:

Insurance Address:

Phone Number:

Group Number:

Policy Number:

Insured's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Secondary Insurance

Orthodontic Coverage? Yes No

Secondary Insurance Company:

Insurance Address:

Phone Number:

Group Number:

Policy Number:

Insured's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Dental History

Medical History

Do you have a personal physician? Yes No

Physician Name:

Phone:

Last Visit:

In case of an emergency, is there someone who lives near you that we should contact? Yes No

Name:

Relation:

Work #:

Home #:

Your current physical health is: Good Fair Poor

Are you currently being treated by a physician? Yes No

Please Explain:

Notice of Privacy Practices

Click the link below to view the Notice of Privacy Practices.

Notice of Privacy Practices

I acknowledge that I have read the notice of privacy practices from Sadler Orthodontics located on their website.

Authorization

I understand that the information I have given above is correct to the best of my knowledge, that where appropriate credit bureau reports will be obtained, and that it will be held in strict confidence. It is my responsibility to inform Dr. Sadler of any changes in my medical and dental status. I hereby authorize release of information for any proposed treatment to my/our insurance company and for insurance payment of said treatment to be paid directly to Sadler Orthodontics. I further authorize release of orthodontic records to other healthcare providers involved in my dental/orthodontic care and the use of these records by Dr. Sadler for teaching purpose and or scientific publication.

Submitted by:

Date: