Adult Intake Form - Clinton Braces

1. About You

Today's Date

First Name

MI

Last Name

Email

Birthdate

Gender

Male Female

Street Address

Street Address Line 2

City

State

Zip Code

Best Phone Number

2. Referral and Dentist

Whom may we thank for referring you?

General Dentist

Last Dental Visit

When was your last dental cleaning?

3. Orthodontic Insurance

Do you have orthodontic coverage?

Yes No

4. Medical and Dental History

What are your concerns regarding your teeth?

Have you previously had orthodontic treatment?

Yes No

Have you ever had jaw pain, clicking, locking, or trouble opening or closing your mouth?

Yes No Not sure

Have there been any traumatic injuries to your face, mouth, or teeth?

Yes No

Do you have any loose or moving permanent teeth?

Yes No Not sure

Have you ever had permanent teeth removed?

Yes No

Do you breathe through your mouth?

Yes No

Are you currently under a physician's care?

Yes No

Your Physician

Physician Phone

Please describe your general health

Good Fair Poor

Please list all medications you are currently taking

Please list any medical conditions you have

Allergies (check all that apply)

Please discuss any conditions checked above

Emergency Contact Name

Emergency Contact Phone

5. Consult Questions

Has the patient already seen a general dentist, or do they need to see one first?

Already referred by general dentist Needs to see general dentist first

Are there any cavities or unfinished dental work still needing treatment?

Yes No

What kind of scheduling works best?

Weekdays are okay Weekdays only Saturday only

Does the patient have any tooth sensitivity or anything else the doctor should know? Type none if not.

Are you interested in aligners or comparing braces and aligners?

Braces only Aligners only Compare both Not sure

Language and Interpreter Support

The language of this form may be different from the language you prefer to speak. These answers help us prepare for your consultation.

What language do you prefer to speak during the consultation?

English / Ingles Espanol / Spanish Another language

Would you like a human interpreter during the consultation?

No Yes Not sure

Automated translation and a human interpreter are separate options.