Young Adult Form

TELL US ABOUT YOU:

Today's Date

Gender:
MaleFemale

Birthdate

Age

School

Who is responsible for making appointments?

PARENT INFORMATION

Does this person have legal custody of you?
YesNo

MOTHER's INFORMATION

Step Mother

Guardian

Name

Birthdate

Work Phone

Home Phone

Employer

SS. #.

How long at current job

Job Title

FATHER's INFORMATION

Step Father

Guardian

Name

Birthdate

Work Phone

Home Phone

How long at current job

Job Title

Person responsible for Account

Name

Relation

Employer

DL #

Work Phone

Home Phone

Social Security #.

Billing Address

Why you have come to dentist today?:

Have you experienced problem with previous dental work?
YesNo

Is your water flouridated?
YesNo

Had you ever had pain/tenderness?
YesNo

In your jaw joint(TMJ/TMD)?
YesNo

Do you brush your teeth daily?
YesNo

Floss your teeth daily?
YesNo

Do your gum bleeds?
YesNo

Dop you require antiboitics before dental work
YesNo

Are you under the care of a physician?
YesNo

Physician's Name

Are you pregnant?:
YesNoUnsureWeek

Date of last visit

Please describe your current physical health
GoodFairPoor

Please list all drugs that your are currently taking

Are you taking a birth control pills?
YesNo

Phone

Are you nursing?
YesNo

For orthodontic treatment please complete the following

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

Have you ever been evaluated/ had orthodontics treatment before?
YesNo

Have there been any injuries to yoy face, mouth, teeth or chin?
YesNo

Have adenoids or tonsils been removed?
YesNo

Have you been informed of any missing or extra permanent teeth?
YesNo

Do you still have your wisdom teeth?
YesNo

Have played any musical instrument?
YesNo

If so, what?

ARE YOU ALLERGIC TO ANY OF THE FOLLOWING

Aspirin
YesNo

Any Metal
YesNo

Plastic
YesNo

Codeine
YesNo

Dental anesthetics
YesNo

Erythomycin
YesNo

Latex
YesNo

Penicillin
YesNo

Tetracycline
YesNo

Other
YesNo

Please list any other Allergies that you have

HAVE YOU EVER HAD ANY OF THE FOLLOWING MEDICAL PROBLEMS?

Abnormal Bleeding
YesNo

Anemia
YesNo

Any hospital stays
YesNo

Asthma
YesNo

Mitral Valve Prolaspe
YesNo

Chicken Pox
YesNo

Congenital Heart Defect
YesNo

Diabetes
YesNo

Convulsions/Epilespy
YesNo

Hepatitis
YesNo

Exposed to HIV, but Neg.
YesNo

HIV+/AIDS
YesNo

Handicaps/Disabilities
YesNo

Hives
YesNo

Hearing Impairment
YesNo

Hemophilia
YesNo

Heart Murmur
YesNo

Measles
YesNo

Kidney Problems
YesNo

Skin Rash
YesNo

Rheumatic/Scarlet Fever
YesNo

Tuberclosis
YesNo

Mononucleosis
YesNo

Cancer
YesNo

Liver Problems
YesNo

DID/DO YOU HAVE ANY OF THE FOLLOWING HABITS?

Nursing Bottle habits
YesNo

Speech Problems
YesNo

Thumb/Finger Sucking
YesNo

Tongue Thrust
YesNo

Clenching/Grinding Teeth
YesNo

Mouth
YesNo

Lip Sucking/Biting
YesNo

Nail Biting
YesNo

Were you breastfed?
YesNo

Used Pacifier?
YesNo

Are you Immunizations current?
YesNo

Please discuss any serious medical problems you've experinced:

Is there anything you would like to discuss with the doctor in private?
YesNo

I understand that I am responsible(If 18 yrs or older) for payment of services rendered and also responsible for paying any co-payment and deductible that may insurance or my parent's does not cover.

Parent Signature

:Date

Parent/Guardian Signature:

Date

Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

I affirm that the information I have given is correct to the best of my knowledge. It will be held on the strictest confidence it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services. I may need.

Signature of Parent/Guardian or Patient:

Date:

This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may at the discretion of this office, use the service of one or more credit reporting services.

Signature of Parent/Guardian or Patient

Date

The Parent or Parent/Guardian is responsible for payment at time of service unless prior arrangements has been approved.

OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY

I verbally reviewed the medical/dental information above the patient name herein. Intials:

Date:

Doctor Comments:

Location

15230 Levan Rd,Suite B, Livonia ,MI 48154 USA

Call us

(734) 522-5520

(734) 522-5522

Book Appointments

(734) 522-5520

(734) 522-5520

Young Adult Form

Young Adult Form

TELL US ABOUT YOU:

Who is responsible for making appointments?

PARENT INFORMATION

MOTHER's INFORMATION

FATHER's INFORMATION

Person responsible for Account

For orthodontic treatment please complete the following

ARE YOU ALLERGIC TO ANY OF THE FOLLOWING

HAVE YOU EVER HAD ANY OF THE FOLLOWING MEDICAL PROBLEMS?

DID/DO YOU HAVE ANY OF THE FOLLOWING HABITS?

More Information

Paltinum Dental Care Services

Come & Say Hi!

15230 Levan Rd,Suite B, Livonia ,MI 48154 USA

(734) 522-5520

(734) 522-5522

Same Day Appointment Available

(734) 522-5520

Same Day Appointment Available

(734) 522-5520

Young Adult Form

Young Adult Form

TELL US ABOUT YOU:

Who is responsible for making appointments?

PARENT INFORMATION

MOTHER's INFORMATION

FATHER's INFORMATION

Person responsible for Account

For orthodontic treatment please complete the following

ARE YOU ALLERGIC TO ANY OF THE FOLLOWING

HAVE YOU EVER HAD ANY OF THE FOLLOWING MEDICAL PROBLEMS?

DID/DO YOU HAVE ANY OF THE FOLLOWING HABITS?

Same Day
Appointment
Available

Same Day
Appointment
Available