New Patient Form

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PATIENT INFORMATION

Patient

Date of Birth

Date

Home Address

Telephone

Mother's Name

Father's Name

E-mail

Referred by

Report for Dr.

Telephone

MEDICAL HISTORY

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

YesNo

2. Are you presently under the care of a physician? If so explain

YesNo

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

YesNo

4. Do you use any prescription or non-prescription medicine regularly?

YesNo

5. Do you have any allergies? Penicillin/ASA/Sulfa/Nickei/Other:

YesNo

6. Do you have or have you ever had any of the following (please check)

DENTAL HISTORY

1. How frequently do you see your dentist?

2. When was your last dental appointment?

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

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

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.