New Patient Forms Riverside Orthodontics Request Consultation View PDF Patient InformationTitleMr.Mrs.Ms.Miss.Dr.Other.Other Patient Name First Middle Last (Name Called) Birthdate MM slash DD slash YYYY Age Sex Male Female AddressCity State NumberZip Code Home PhoneWork PhoneCell PhoneSocial Security # School or Employer E-mail Emergency Contact & PhoneFinancial InformationTitleMr.Mrs.Ms.Miss.Dr.Other.Other Responsible Party First Middle Last Marital Status Married Unmarried Mailing AddressCity State Zip Code Home PhoneWork PhoneCell PhoneSocial Security # Birthdate MM slash DD slash YYYY Relationship to Patient E-Mail Employer Please 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.Other Responsible Party First Middle Last Marital Status Married Unmarried Mailing AddressCity State Zip Code Home PhoneWork PhoneCell PhoneSocial Security # Bithdate MM slash DD slash YYYY Reationship to Patient E-Mail Employer Dental Insurance InformationSubscriber's Full Name Birthdate MM slash DD slash YYYY Subscriber's Mailing AddressCity State Zip Code Subscriber's Social Security # Insured's ID # Insured's Group # Primary Dental Insurance Company Insurance 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 Dentist Have you ever received orthodontic treatment? Yes No Explain:Have you ever been treated for Periodontal or TMJ treatment? Yes No ExplainPhysician Known Medical Problems Allergies Medication Accidents (medical or dental)Any manjor illness, or hospitalization Illness 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, Interests Habits Such as Finger Sucking or Nail Biting Describe your child's temperamentSibling InformationSibling Name Birthdate MM slash DD slash YYYY Any Orthodontic Problems? Yes No Sibling Name Birthdate MM slash DD slash YYYY Any Orthodontic Problems? Yes No Sibling Name Birthdate 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.Signature Date MM slash DD slash YYYY Relationship CAPTCHA Δ Your Smile, Your Way Your perfect smile is just a consultation away! Request Consultation