New Patient Form - Blue Wave Orthodontics

Submit your health history form online to your orthodontist today.
Save time at the doctor’s office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form and click “submit”. Your information will be sent to our office with secure encryption. We will have your information when you arrive for your first appointment.
Patient Information
Date

MonthDayYear
Date
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Birthday

MonthDayYear
Date
Marital Status
Sex
If patient is a minor, parent's / guardian's name
If patient is a minor, name and ages of siblings
Email
example@example.com
Whom may we thank for referring you to our office?
Sports/Hobbies/Musical Instruments
School/Occupation
Current Grade
Nickname
Patient Information
Same as Above?
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Have you been at this address longer than 3 years?
Previous Address

Street Address

Street Address Line 2

CityState

Zip Code
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Social Security #
Relationship to Patient
Employer
Occupation
No. of years employed
Spouse's Name
Sex
Relationship to Patient
Spouse's Employer
Occupation
No. of years employed
Social Security #
Birthday

MonthDayYear
Date
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Dental Insurance Information
Insured's Name
Insured's Birthdate

MonthDayYear
Date
Social Security #
Insurance Company
Group No.
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Co. Address

Street Address

Street Address Line 2

CityState

Zip Code
Insured's Employer
Subscriber/Employee ID #
Do you have dual coverage?
IF YES:
Insured's Name
Insured's Birthdate

MonthDayYear
Date
Social Security #
Insurance Company
Group No.
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Co. Address

Street Address

Street Address Line 2

CityState

Zip Code
Insured's Employer
Subscriber/Employee ID #
Emergency Information
Name of nearest relative not living with you
Relationship
Cell or Phone
Please enter a valid phone number.Format: (000) 000-0000.
Complete Address

Street Address

Street Address Line 2

CityState

Zip Code
What are the main concerns that you would like orthodontics to address?
Please describe concerns
Has the patient ever been evaluated for or had orthodontic treatment before?
Have there been any injuries to the face, mouth, teeth or chin?
How does the patient feel about wearing orthodontic appliances?
Have adenoids or tonsils been removed?
Has the patient been informed of any missing or extra permanent teeth?
Has the patient ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?
Does the patient brush his/her teeth daily?
Floss his/her teeth daily?
Patient's Dentist
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Date of Last Visit

MonthDayYear
Date
Patient's Physician
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Is the patient currently under the care of a physician?
If patient is a minor, has puberty begun?
If yes, when?
Please describe the patient's current physical health
Do you take or have you taken an osteoporosis medication?
Please list all drugs that the patient is currently taking
Please list all allergies (drugs, foods, other)
Has the patient ever had any of the following medical problems?
Please discuss any medical problems that the patient has had
Does/Has the patient have/had any of the following habits?
Signatures
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

Please check your form to make sure it is complete and press the submit button when you are done. You will see a confirmation page when your form has been successfully submitted. Thank you!
Should be Empty:

Patient Information

Patient Information

Dental Insurance Information

Emergency Information

What are the main concerns that you would like orthodontics to address?

Signatures