Adult Patient Registration

_2017 Adult Registration Form – Ortho Custom

Patient Information

Gender:

Your General Dentist

Spouse / Partner Information

Responsible Party and Insurance Information

Primary Orthodontic Insurance

Orthodontic Coverage?

Secondary Insurance

Orthodontic Coverage?

Dental History

Are you currently in pain?
Have you ever had a serious/difficult problem with any previous dental work?
Do you like your smile?
Do your gums bleed?
Have you ever been evaluated by an orthodontist or had orthodontic treatment?
Have you ever had severe injuries to the face, teeth, mout or chin?
Do you have any missing or extra permanent teeth?
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?

Medical History

Do you have a personal physician?
In case of an emergency, is there someone who lives near you that we should contact?
Your current physical health is:
Are you currently being treated by a physician?
Are you currently taking any prescription or over-the-counter medications?
(Women) Are you taking birth control pills?
(Women) Are you pregnant?
Check if you have ever had any of the following:

Notice of Privacy Practices

Click the link below to view the Notice of Privacy Practices.

Notice of Privacy Practices

Authorization

I understand that the information I have given above is correct to the best of my knowledge, that where appropriate credit bureau reports will be obtained, and that it will be held in strict confidence. It is my responsibility to inform Dr. Sadler of any changes in my medical and dental status. I hereby authorize release of information for any proposed treatment to my/our insurance company and for insurance payment of said treatment to be paid directly to Sadler Orthodontics. I further authorize release of orthodontic records to other healthcare providers involved in my dental/orthodontic care and the use of these records by Dr. Sadler for teaching purpose and or scientific publication.



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Sadler Orthodontics

  • Fishers Office - 11921 Lakeside Dr., Fishers, IN 46038 Phone: (317) 594-0888
  • New Castle Office - 916 S. Main St., New Castle, IN 47362 Phone: (765) 521-4500
  • Richmond Office - 1923 Chester Blvd., Richmond, IN 47374 Phone: (765) 935-5251

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