Adult New Patient Information

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Adult Registration Form - Dental

Patient Information

* Patient Name: (Required) Social Security Number: Birth Date: Home Address:

Primary Phone: home cell Ok to leave message? Yes No

Secondary Phone: home cell other Ok to leave message? Yes No

E-mail: Employer's Name: Occupation:

General Dentist
Last Visit

How did you hear about our Practice? Ad Internet Family or Friend Physician Other
Name of person referring (if applicable)

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

Have you visited an orthodontist before? Yes No
When Reason

Do you currently or have you ever had any of the following habits?

Clenching/Grinding Teeth Lip Sucking/Biting Mouth Breathing

Nail Biting Thumb/ Finger Sucking Chewing/Eating Problems

Are you currently being treated by a physician? Yes No
Physician: Last Visit:

Are you currently taking any prescription or over-the-counter medications? Yes No
Please list, with dosage:

Check if you have or have ever had any of the following:

Asthma Blood Disease Diabetes Epilepsy Heart Problems Kidney Disease Rheumatic Fever

Submitted by: Date:

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Marshall Fleer, DDS

Marshall Fleer, DDS - 177 Main St., East Brunswick, NJ 08816 Phone: 732-254-1244