ADULT INFORMATION

Dr/Mr/Mrs/Ms ___________________________ Preferred name______________ M/F

Address __________________________________________________________ZIP________

Home phone________________ Cell phone ______________ Birth date _____________

Age ____________ How long at current address? ____________________ Rent/Own

Social Security #___________________ Email address ___________________________ General Dentist________________________________ Date of last visit _____________

Employer ____________________________________ Work Phone __________________ Occupation _______________________ How long at current job? _________________

What style of braces are you interested in? ______________ Invisalign? _________

What is your primary concern for today’s visit? _______________________________

______________________________________________________________________________

Have you had previous orthodontic treatment? __________ at what age? ________

Whom may we thank for referring you to our office? ___________________________

Which office is most convenient for you? San Clemente? San Juan Capistrano?

ADDITIONAL INFORMATION

SELF SPOUSE

Dental Insurance __________________ Name _____________________________

Social Sec # _______________________ Address ___________________________

Ins Co. phone # ___________________ ___________________________________

FOR OFFICE USE: Employer _________________________

Benefits_____________@__________% Occupation _______________________

Used _________ How paid __________ Cell phone ________________________

Deductible _______________________ SS# ________________DOB __________

Notes ____________________________ Dental Insurance __________________