Patient Forms

Printed Forms

You may access the following forms to assist us with your care. Please print and fill out the following forms, and bring them to your appointment.

adobe

 *These forms require Adobe Acrobat Reader. Click the Adobe logo to download.

 


Online Forms

You may access the following forms to assist us with your care. Please complete the following forms, and click the "Submit" button at the bottom of each form.

Child New Patient Forms

Adult New Patient Forms

*We are committed to keeping your personal information secure. All of our online forms are submitted via a secure connection and are HIPAA compliant.

Raritan Valley Orthodontics Child Registration Form

Tell Us About Your Child

Gender:

Who is Accompanying Your Child Today?

Do you have legal custody of this child?
Parent's Marital Status:

Parents

Mother's Information

Relation:

Father's Information

Relation:

Person Responsible For Account

Do you own or rent?

Who is responsible for making appointments?

Insurance Information

Primary Orthodontic Insurance

Orthodontic Coverage?

Secondary Orthodontic Insurance

Orthodontic Coverage?

Medical History

Has your child ever taken Phen-Fen?
Has your child ever been evaluated or had orthodontic treatment before?
Have there been any injuries to the face, mouth, teeth, or chin?
Have adenoids or tonsils been removed?
Has your child been informed of any missing or extra permanent teeth?
Has your child ever had any pain / tenderness in his / her jaw joint (TMJ/TMD)?
Does your child brush his / her teeth daily?
Floss his / her teeth daily?
Is your child currently under the care of a physician?
Has puberty begun?
Has menstruation begun? (Girls)
Please describe your child's current physical health?
Allergic to:
Has your child ever had any of the following medical problems?
Has your child ever experienced any of the following?

Neighbor or Relative not living with you.

Authorization

I understand that the information that I have given is correct to the best of my knowledge, that it be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.

I authorize the dental staff to perform the necessary dental services my child may need.

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 services of one or more credit reporting services.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits directly to this office. I authorize the use ofthis signature on all my insurance submissions, whether manual or electronic.

The Parent or Guardian who accompanies the child is responsible for payment.
Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.



Security Measure
Belle Mead Orthodontics Child Registration Form

Tell Us About Your Child

Gender:

Who is Accompanying Your Child Today?

Do you have legal custody of this child?
Parent's Marital Status:

Parents

Mother's Information

Relation:

Father's Information

Relation:

Person Responsible For Account

Do you own or rent?

Who is responsible for making appointments?

Insurance Information

Primary Orthodontic Insurance

Orthodontic Coverage?

Secondary Orthodontic Insurance

Orthodontic Coverage?

Medical History

Has your child ever taken Phen-Fen?
Has your child ever been evaluated or had orthodontic treatment before?
Have there been any injuries to the face, mouth, teeth, or chin?
Have adenoids or tonsils been removed?
Has your child been informed of any missing or extra permanent teeth?
Has your child ever had any pain / tenderness in his / her jaw joint (TMJ/TMD)?
Does your child brush his / her teeth daily?
Floss his / her teeth daily?
Is your child currently under the care of a physician?
Has puberty begun?
Has menstruation begun? (Girls)
Please describe your child's current physical health?
Allergic to:
Has your child ever had any of the following medical problems?
Has your child ever experienced any of the following?

Neighbor or Relative not living with you.

Authorization

I understand that the information that I have given is correct to the best of my knowledge, that it be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.

I authorize the dental staff to perform the necessary dental services my child may need.

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 services of one or more credit reporting services.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits directly to this office. I authorize the use ofthis signature on all my insurance submissions, whether manual or electronic.

The Parent or Guardian who accompanies the child is responsible for payment.
Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.



Security Measure
Brunswick Valley Orthodontics Child Registration Form

Tell Us About Your Child

Gender:

Who is Accompanying Your Child Today?

Do you have legal custody of this child?
Parent's Marital Status:

Parents

Mother's Information

Relation:

Father's Information

Relation:

Person Responsible For Account

Do you own or rent?

Who is responsible for making appointments?

Insurance Information

Primary Orthodontic Insurance

Orthodontic Coverage?

Secondary Orthodontic Insurance

Orthodontic Coverage?

Medical History

Has your child ever taken Phen-Fen?
Has your child ever been evaluated or had orthodontic treatment before?
Have there been any injuries to the face, mouth, teeth, or chin?
Have adenoids or tonsils been removed?
Has your child been informed of any missing or extra permanent teeth?
Has your child ever had any pain / tenderness in his / her jaw joint (TMJ/TMD)?
Does your child brush his / her teeth daily?
Floss his / her teeth daily?
Is your child currently under the care of a physician?
Has puberty begun?
Has menstruation begun? (Girls)
Please describe your child's current physical health?
Allergic to:
Has your child ever had any of the following medical problems?
Has your child ever experienced any of the following?

Neighbor or Relative not living with you.

Authorization

I understand that the information that I have given is correct to the best of my knowledge, that it be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.

I authorize the dental staff to perform the necessary dental services my child may need.

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 services of one or more credit reporting services.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits directly to this office. I authorize the use ofthis signature on all my insurance submissions, whether manual or electronic.

The Parent or Guardian who accompanies the child is responsible for payment.
Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.



Security Measure
Warren Hills Orthodontics Child Registration Form

Tell Us About Your Child

Gender:

Who is Accompanying Your Child Today?

Do you have legal custody of this child?
Parent's Marital Status:

Parents

Mother's Information

Relation:

Father's Information

Relation:

Person Responsible For Account

Do you own or rent?

Who is responsible for making appointments?

Insurance Information

Primary Orthodontic Insurance

Orthodontic Coverage?

Secondary Orthodontic Insurance

Orthodontic Coverage?

Medical History

Has your child ever taken Phen-Fen?
Has your child ever been evaluated or had orthodontic treatment before?
Have there been any injuries to the face, mouth, teeth, or chin?
Have adenoids or tonsils been removed?
Has your child been informed of any missing or extra permanent teeth?
Has your child ever had any pain / tenderness in his / her jaw joint (TMJ/TMD)?
Does your child brush his / her teeth daily?
Floss his / her teeth daily?
Is your child currently under the care of a physician?
Has puberty begun?
Has menstruation begun? (Girls)
Please describe your child's current physical health?
Allergic to:
Has your child ever had any of the following medical problems?
Has your child ever experienced any of the following?

Neighbor or Relative not living with you.

Authorization

I understand that the information that I have given is correct to the best of my knowledge, that it be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.

I authorize the dental staff to perform the necessary dental services my child may need.

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 services of one or more credit reporting services.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits directly to this office. I authorize the use ofthis signature on all my insurance submissions, whether manual or electronic.

The Parent or Guardian who accompanies the child is responsible for payment.
Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.



Security Measure
Raritan Valley Orthodontics Adult Registration Form

About You

Gender:
Marital Status:

Spouse Information

Person Responsible for Account

Insurance Information

Primary Insurance

Orthodontic Coverage?
Dental Coverage?

Secondary Insurance

Orthodontic Coverage?
Dental Coverage?

In the event of an emergency, is there someone who lives near you that we should contact?

Medical History

Do you have a personal physician?
Your current physical health is:
Are you currently under the care of a physician?
Are you taking any prescription / over-the-counter drugs?

For Women:

Are you using a prescribed method of birth control?
Are you pregnant?
Nursing?

Have you ever had any of the following diseases or medical problems?

Are you allergic to any of the following?

Dental History

Have you ever had or been evaluated for orthodontic treatment?
Have you ever had a serious / difficult problem associated with any previous dental work?
Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ/TMD)?
Your current dental health is:
Do you like your smile?
Gums ever bleed?
Have you ever had an injury to your:
Do you generally breathe through your mouth?
If yes, when?
Do you have any missing or extra permanent teeth?
Have you ever taken Fosamax, or any other bisphosphonate?
Have you ever taken Phen-Fen?
Do you smoke or use tobacco in any form?

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status.

I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.



Security Measure
Belle Mead Orthodontics Adult Registration Form

About You

Gender:
Marital Status:

Spouse Information

Person Responsible for Account

Insurance Information

Primary Insurance

Orthodontic Coverage?
Dental Coverage?

Secondary Insurance

Orthodontic Coverage?
Dental Coverage?

In the event of an emergency, is there someone who lives near you that we should contact?

Medical History

Do you have a personal physician?
Your current physical health is:
Are you currently under the care of a physician?
Are you taking any prescription / over-the-counter drugs?

For Women:

Are you using a prescribed method of birth control?
Are you pregnant?
Nursing?

Have you ever had any of the following diseases or medical problems?

Are you allergic to any of the following?

Dental History

Have you ever had or been evaluated for orthodontic treatment?
Have you ever had a serious / difficult problem associated with any previous dental work?
Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ/TMD)?
Your current dental health is:
Do you like your smile?
Gums ever bleed?
Have you ever had an injury to your:
Do you generally breathe through your mouth?
If yes, when?
Do you have any missing or extra permanent teeth?
Have you ever taken Fosamax, or any other bisphosphonate?
Have you ever taken Phen-Fen?
Do you smoke or use tobacco in any form?

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status.

I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.



Security Measure
Brunswick Valley Orthodontics Adult Registration Form

About You

Gender:
Marital Status:

Spouse Information

Person Responsible for Account

Insurance Information

Primary Insurance

Orthodontic Coverage?
Dental Coverage?

Secondary Insurance

Orthodontic Coverage?
Dental Coverage?

In the event of an emergency, is there someone who lives near you that we should contact?

Medical History

Do you have a personal physician?
Your current physical health is:
Are you currently under the care of a physician?
Are you taking any prescription / over-the-counter drugs?

For Women:

Are you using a prescribed method of birth control?
Are you pregnant?
Nursing?

Have you ever had any of the following diseases or medical problems?

Are you allergic to any of the following?

Dental History

Have you ever had or been evaluated for orthodontic treatment?
Have you ever had a serious / difficult problem associated with any previous dental work?
Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ/TMD)?
Your current dental health is:
Do you like your smile?
Gums ever bleed?
Have you ever had an injury to your:
Do you generally breathe through your mouth?
If yes, when?
Do you have any missing or extra permanent teeth?
Have you ever taken Fosamax, or any other bisphosphonate?
Have you ever taken Phen-Fen?
Do you smoke or use tobacco in any form?

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status.

I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.



Security Measure
Warren Hills Orthodontics Adult Registration Form

About You

Gender:
Marital Status:

Spouse Information

Person Responsible for Account

Insurance Information

Primary Insurance

Orthodontic Coverage?
Dental Coverage?

Secondary Insurance

Orthodontic Coverage?
Dental Coverage?

In the event of an emergency, is there someone who lives near you that we should contact?

Medical History

Do you have a personal physician?
Your current physical health is:
Are you currently under the care of a physician?
Are you taking any prescription / over-the-counter drugs?

For Women:

Are you using a prescribed method of birth control?
Are you pregnant?
Nursing?

Have you ever had any of the following diseases or medical problems?

Are you allergic to any of the following?

Dental History

Have you ever had or been evaluated for orthodontic treatment?
Have you ever had a serious / difficult problem associated with any previous dental work?
Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ/TMD)?
Your current dental health is:
Do you like your smile?
Gums ever bleed?
Have you ever had an injury to your:
Do you generally breathe through your mouth?
If yes, when?
Do you have any missing or extra permanent teeth?
Have you ever taken Fosamax, or any other bisphosphonate?
Have you ever taken Phen-Fen?
Do you smoke or use tobacco in any form?

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status.

I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.



Security Measure

Five Star Orthodontics

  • Raritan Valley Orthodontics - 901 Route 202 N., Raritan, NJ 08869 Phone: (908) 231-1860 Fax: (908) 231-7945
  • Warren Hills Orthodontics - 9 Mt. Bethel Rd. Unit 37B, Warren, NJ 07059 Phone: (908) 222-0101 Fax: (908) 222-0059
  • Brunswick Valley Orthodontics - 3176 Route 27, Suite 1B, Kendall Park, NJ 08824 Phone: (732) 398-1900 Fax: (732) 398-9791
  • Belle Mead Orthodontics - 2139 Route 206, Belle Mead, NJ 08502 Phone: (908) 874-8360 Fax: (908) 874-5985

2019 © All Rights Reserved | Website Design By: West | Login