New Patient Form

Select Office Location

PATIENT INFORMATION

Patient Name

Date of Birth

Current Date

Home Address

Telephone - Home

Telephone - Cell

Mother's Name (if applicable)

Father's Name (if applicable)

E-mail Address

Referred by

Report for Dr.

Telephone

MEDICAL HISTORY

1. Have you had any serious illnesses requiring hospitalization or extensive medical care? If yes, specify:

YesNo

2. Are you presently under the care of a physician? If yes, explain:

YesNo

3. Have you had a medical examination in the last year?

YesNo

4. Have you recently, or are you presently, taking any PRESCRIPTION or NON-PRESCRIPTION drugs? Please list:

YesNo

5. Do you have any allergies? Penicillin/ASA/Sulfa/Nickei/Other. If Other, Please specify:

YesNo

Other present or past conditions, please specify here:

DENTAL HISTORY

1. How frequently do you see your dentist?

2. Date of your last dental visit?

3. What type of dental treatment have you had in the past?

4. Have you ever had any jaw joint (TMJ) problems?

YesNo

Please indicate:

Pain in your jaw points, around your ears or side of your facePopping/clicking of your jaw pointsPain when teeth are clenchedDifficulty in opening or closingPain or difficulty while chewingClenching or grinding your teeth while away or asleep

I/We acknowledge and agree that the office of Dr. Eggert Boehlau can collect, use and disclose personal information about me/my child to assess my/his/her health needs and risks, and to provide safe and efficient orthodontic care.

In addition, 1/We authorize the office of Dr. Boehlau to communicate with other treating health-care providers, including other specialists and general dentists, and/or referring dentists, physicians, pharmacists, as well as third_party insurance carriers.