New Patient Forms Riverside Orthodontics Request Consultation View PDF Patient InformationTitleMr.Mrs.Ms.Miss.Dr.Other.OtherPatient Name First Middle Last (Name Called) Birthdate MM slash DD slash YYYY AgeSex Male Female AddressCityStateNumberZip CodeHome PhoneWork PhoneCell PhoneSocial Security #School or EmployerE-mail Emergency Contact & PhoneFinancial InformationTitleMr.Mrs.Ms.Miss.Dr.Other.OtherResponsible Party First Middle Last Marital Status Married Unmarried Mailing AddressCityStateZip CodeHome PhoneWork PhoneCell PhoneSocial Security #Birthdate MM slash DD slash YYYY Relationship to PatientE-Mail EmployerPlease Circle one choice belowThe financial party above agrees to pay in full at the time of the patient's appointment: Cash Check Visa Master Card American Express Second Person InformationTitleMr.Mrs.Ms.Miss.Dr.Other.OtherResponsible Party First Middle Last Marital Status Married Unmarried Mailing AddressCityStateZip CodeHome PhoneWork PhoneCell PhoneSocial Security #Bithdate MM slash DD slash YYYY Reationship to PatientE-Mail EmployerDental Insurance InformationSubscriber's Full NameBirthdate MM slash DD slash YYYY Subscriber's Mailing AddressCityStateZip CodeSubscriber's Social Security #Insured's ID #Insured's Group #Primary Dental Insurance CompanyInsurance PhonePrimary Insurance AddressConsent I hereby autorize Dr. Kesselman's office to submit all insurance, as a courtesy, on my behalf. I acknoweldge that I am responsible for the costs of incurred at the time of service.Please be aware that it is your responsibility as the patient/guardian to inform us when your insurance company changes.Medical InformationWho referred you to our practice?Regular DentistHave you ever received orthodontic treatment? Yes No Explain:Have you ever been treated for Periodontal or TMJ treatment? Yes No ExplainPhysicianKnown Medical ProblemsAllergiesMedicationAccidents(medical or dental)Any manjor illness, or hospitalizationIllness Diabetes HIV Virus Heart Murmur Tuberclosis Heart Trouble Rheumatic Fever Hepatitis / Liver Problems Prolonged Bleeding Anemia High Blood Pressure Arthrities Endocrine Probelms Bone Disorder Fainting or Dizziness Seizure / Epilpsy Asthma For younger female patients; When did menses begin?Woman: are you pregnant? Yes No Social InformationFavorite Hobbies, Sports, InterestsHabits Such as Finger Sucking or Nail BitingDescribe your child's temperamentSibling InformationSibling NameBirthdate MM slash DD slash YYYY Any Orthodontic Problems? Yes No Sibling NameBirthdate MM slash DD slash YYYY Any Orthodontic Problems? Yes No Sibling NameBirthdate MM slash DD slash YYYY Any Orthodontic Problems? Yes No Declaration To the best of my knowledge the information above is accurate and complete.I authorize Dr. kesselman and/or staff to provide dental treatment and I agreeto be responsible for expenses incurred I understand it to be my responsibility to inform this office of any medical changes.SignatureDate MM slash DD slash YYYY RelationshipCAPTCHA Δ Your Smile, Your Way Your perfect smile is just a consultation away! Request Consultation