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PATIENT FORMS

Hambleton & MacFarlane Orthodontics New Patient Information

Welcome to Hambleton & MacFarlane Orthodontics! We're grateful you chose us to care for your smile, and we look forward to serving you. We recommend filling out this confidential registration and health history information online. Enter your answers, click the "Submit" button at the bottom, and your information will be sent to our office with secure encryption. If you prefer a physical form that you can fill out and bring with you, simply text or call us. Please let us know if you have any questions.

First Name

Middle Name

Last Name

Preferred Name/Nickname if any

Patient Address

Street

Mailing Address (if different)

City

State/Province

Zip/Postal Code

Email Address

Patient Cell/Primary Phone

Patient Secondary or Guardian Phone

Patient Birthdate MM-DD-YYYY

Gender

Is Patient a Minor?

Yes

No

How Did You Hear About Hambleton & MacFarlane Orthodontics?

Responisble Party Information (if different than Patient)

Full Name of Financially responsible party

Relationship to Patient

Address (if different than patient)

Mailing Address (if different)

Email Address

Cell Phone

Secondary Phone

Guardian's Information if Patient is a Minor

Guardian's Name

Cell Phone

Email Address

Dental Insurance Information

Do you have Dental/Orthodontic Insurance?

Insured's Name

Insured's Birth Date

Insured's Social Security Number

Insurance Company

Insurance Company Phone Number

ID Number/Group Number

If you have additional coverage, please also provide subscriber and policy details below

Emergency Information

Name of back-up emergency contact

Primary Phone

Relationship to Patient

Patient Dental History

Dentist Name

Dentist Phone Number

Approximate Date of last dental appointment

How often do you brush and floss

Who recommended or promted you to see orthodontic treatment?

Have you been evaluated for orthodontic treatment before?

Have you had braces or aligners before?

List any questions and/or concerns you have about your teeth/smile

Have you ever lost or chipped any permanent teeth?

Yes

No

Have you had any injuries to your face, mouth, jaw or chin?

Yes

No

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

Yes

No

Do you ever have jaw pain, tenderness or discomfort?

Yes

No

Are you aware of your jaw clicking or popping?

Yes

No

Do you get tension headaches?

Yes

No

Have you had adenoids or tonsils removed?

Yes

No

Patient Medical History

Physician

Physician Phone

Approximate date of last visit

Are you currently under a doctors care?

How would you describe your current health

List medications (including non- prescription)

Are you allergic to any medication you are aware of?

Are you now or have you ever taken bisphosphonates? For example: Fosamax, Actonel, Boniva, etc.)

Please describe if you have ever been hospitalized for surgery, serious accident or illness

Are there additional details you want to provide or any medical conditions not listed that we should be aware of?

Signature

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PATIENT FORMS

Hambleton & MacFarlane Orthodontics New Patient Information

Responisble Party Information (if different than Patient)

Dental Insurance Information

Emergency Information

Patient Dental History

Patient Medical History

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Contact

info@hambletonorthodontics.com
(626) 795-0634

200 S Oak Knoll Ave #201
Pasadena, CA 91101-2999