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Hollywood, MD

Phone

(240) 316-4004

Address

44220 Airport View Rd. Hollywood, MD 20636

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Copyright (c) 2021 Patuxent Orthodontics

New Patient Form

Step 1 of 5

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Please fill this form out and submit it prior to your first consultation.

For your convenience, our New Patient Forms are completely electronic – no need to print and bring in any paperwork!

Please have your dental insurance information on hand. By providing your dental insurance information, we are able to pre-determine any orthodontic benefits prior to your initial consultation. This information will allow us to provide you a more accurate accounting of what your out-of-pocket, orthodontic investment will be.

This form is expected to take 15-20 minutes to complete.

Patient's Name*
First Last
Name Patient Prefers To Be Called
Patient's Date of Birth*
Patient's Sex*
- Male
- Female
Patient's Home Address*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian Name
First Last
If applicable.
Parent/Guardian Home Phone
Patient's School
If applicable.
Patient's Sports/Hobbies
How did you hear about us?*

Primary Insurance
The information required for this section can be found on the front and back of your insurance card. If your insurance company does not provide a card, please call to find this information as it allows us to verify your benefits and coverage details before your appointment which can prevent you from paying unnecessary fees.
Does the patient have DENTAL insurance coverage?*
- Yes
- No
Primary Insurance Company*
Primary Insurance Phone
The number is located on the back of your insurance card. Please provide the "provider" number if available.
Policy Holder's Name*
First Last
Policy Holder's Date of Birth*
Insurance ID #*
If no ID available, please enter "0" and call us to provide the Insured's SSN.
Policy Holder's Social Security Number If you do not have an insurance ID, we use your social security number to acquire benefit information. In order to protect your data, we only accept SSNs over the phone. Please call our office to provide your SSN.
Group Number
Policy Holder's Employer
Secondary Insurance
Does the patient have SECONDARY DENTAL insurance coverage?
- Yes
- No
Secondary Insurance Company*
Secondary Insurance Phone
The number is located on the back of your insurance card. Please provide the "provider" number if available.
Policy Holder's Name*
First Last
Policy Holder's Date of Birth*
Insurance ID #*
If no ID available, please give the Insured's SSN
Group Number

General Health History
Name of Patient's Primary Care Physician
First Last
Physician's Phone
Is the patient in overall good health?*
- Yes
- No
Does the patient have any history of major illnesses?*
- Yes
- No
Check any of the following for which the patient has been diagnosed or treated:
- ADD/ADHD
- AIDS/HIV
- Asthma
- Bone Disorders
- Blood Disease
- Artificial Heart Valve
- Diabetes
- Liver Disease
- Pneumonia
- Hepatitis
- Kidney Disease
- Fainting or Dizziness
- Heart Murmur
- Abnormal Bleeding
- Cancer
- Chemical Dependency
- Prolonged Bleeding
- Epilepsy
- Depression
- Mental Illness
- Transplants
- Seizures
- Artificial Joints
- Chemo or Radiation
- Endocrine Problems
- Rheumatic Fever
- Nervous Disorder
- Tuberculosis
- Eating Disorder
- None
- Other
Other (if checked above):
Please answer yes or no to the following:
Has the patient had any surgeries or hospitalizations in the past year?*
- No
- Yes
Please list all surgeries and hospitalizations within the past year:
Is the patient allergic to any foods, medications, or metals?*
- No
- Yes
Please list all food, medication, and metal related allergies:
Allergic to latex?*
- No
- Yes
Allergic to nickel?*
- No
- Yes
Trouble wearing jewelry?*
- No
- Yes
Pregnant? (females only)*
- No
- Yes
Nursing? (females only)*
- No
- Yes
Is the patient currently taking any medications?*
- No
- Yes
Please list current medications:

General Dental History
Name of Patient's Dentist*
If patient doesn't have one, type NONE.
Dentist's Phone
When was the patient's last dental appointment?
Approximate date is acceptable.
Has the patient had any injuries to the face, mouth, or teeth?*
- No
- Yes
Please describe injuries:
Please indicate yes or not to the questions below:
Started teething very early or late?*
- No
- Yes
Baby teeth removed that were NOT loose?*
- No
- Yes
Congenitally missing teeth?*
- No
- Yes
Supernumerary (extra) teeth removed?*
- No
- Yes
Chipped or otherwise injured baby/permanent teeth?*
- No
- Yes
Jaw fractures, cysts, or mouth infections?*
- No
- Yes
Sensitivity to hot/cold or teeth throb/ache?*
- No
- Yes
Bleeding gums, bad taste or mouth odor?*
- No
- Yes
Periodontal "gum problems"?*
- No
- Yes
Had periodontal "gum treatment"?*
- No
- Yes
Root canals or "dead" teeth?*
- No
- Yes
Food impaction in between teeth?*
- No
- Yes
Frequent cold or canker sores?*
- No
- Yes
History of speech problems?*
- No
- Yes
Ever sucked a thumb or fingers?*
- No
- Yes
Breathe through his/her mouth while awake?*
- No
- Yes
Breathe through his/her mouth while asleep?*
- No
- Yes
Grind teeth at night?*
- No
- Yes
Jaw clenching, clicking, or locking?*
- No
- Yes
Any teeth irritating the cheek, lip, tongue, or palate?*
- No
- Yes
Been treated for "TMJ" or "TMD"?*
- No
- Yes
Aware or concerned about over or under developed jaw relationships?*
- No
- Yes
Any wisdom tooth problems?*
- No
- Yes
Had any serious trouble with previous dental treatment?*
- No
- Yes
If yes to any of the above, please describe:
Acknowledgment
I have read and understand the questions above. I will not hold Dr. Richard Lee, Loudoun Orthodontics/ Patuxent Orthodontics, or any member of his staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record/dental status, I understand that it is my responsibility to inform Dr. Richard Lee as soon as I can while in treatment. I acknowledge by clicking this box that I agree to the previous statement as well as verify that my typed name below as my digital signature.
*
- I acknowledge
Signature*

ITERO SCANNER

Use this simple form to request an appointment. We will try to accommodate your requested time and make it as convenient as possible for you!
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INVISALIGN

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RETENTION

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ADULT TREATMENT

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ADOLESCENT TREATMENT

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EARLY EVALUATION

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