New Patient Form - Adult

Welcome to Tri-Valley Orthodontics! Please complete the form below (along with the Adult Medical & Dental History Form and HIPAA Form) and submit them prior to your complimentary consultation. If you prefer to fill out the form on paper please refer to our Forms link to print, scan and email them to us at info@tri-ortho.com.

Submitting your forms prior to your visit will save a lot of time at your initial visit, so you can get right to getting your records done & meeting with Dr. Ko or Dr. Yoon. We’re looking forward to meeting you soon!

Today's Date

YYYY

Welcome! How did you hear about us?

Primary reason for consultation - what is your chief concern?:

Is this your first orthodontic consultation?

Yes

Have you had any previous orthodontic treatment?

Are you currently wearing any appliances (such as a nightguard) or retainers? Please detail here what type and how often it is worn:

PATIENT INFORMATION

Patient's Name

First Name

Last Name

Primary Email (IMPORTANT - All office correspondence & appointment reminders will be sent here)

Patient's date of birth

YYYY

Primary phone number (IMPORTANT - All appointment reminders will be sent here via text)

(###)

###

####

Alternate phone number

(###)

###

####

Primary Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your Occupation:

Your Employer:

Work Phone:

(###)

###

####

Work Address:

GENERAL DENTAL INFORMATION

Date of last cleaning with your General Dentist

YYYY

General Dentist's Name

First Name

Last Name

City in which your General Dentist's office is located:

General Dentist Phone Number

(###)

###

####

SPOUSE INFORMATION (IF APPLICABLE)

Full Name

First Name

Last Name

Home Address (If different from patient's address)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address:

Phone Number

(###)

###

####

Occupation:

Employer:

PERSON ASSUMING FINANCIAL RESPONSIBILITY (If different from above)

If the person assuming financial responsibility is different from either the patient (yourself) or the spouse (if applicable) please fill out the below section - otherwise please skip to the "Primary Insurance Information" section below:

Name:

First Name

Last Name

Relationship to Patient:

Phone Number

(###)

###

####

Email Address:

Home Address:

PRIMARY INSURANCE INFORMATION (If you have already provided your insurance information please skip to the bottom and submit your NP Form)

Please provide your dental insurance information (if applicable) prior to your consultation - nothing will be charged to your insurance before your consultation visit - your consultation is completely complimentary. As a service to you, we'll verify your orthodontic benefits for you and be able to provide you with an accurate estimate of treatment at your consultation visit.

Do you have dental insurance you'd like us to verify for you ahead of your consultation? To give our insurance coordinator time to verify your benefits - please complete the below section ahead of your visit:

Yes - Please complete the insurance information requested below

No - Please skip this next portion and click the submit button below.

Will your insurance policy by changing or terminating soon?

If so please contact our Insurance Coordinator at Frontdesk@tri-ortho.com, as this will change your expected benefits.

Policy Holder Name:

First Name

Last Name

Employer Name:

Insurance Company Name:

Policy Holder Date of Birth:

YYYY

Insurance Phone Number:

(###)

###

####

Subscriber ID:

Group Number:

SECONDARY INSURANCE INFORMATION (If Applicable)

Policy Holder Name:

First Name

Last Name

Policy Holder Date of Birth:

YYYY

Employer Name:

Insurance Company Name:

Insurance Phone Number:

(###)

###

####

Group Number:

Subscriber ID:

New Patient Form - Adult

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