Online Adult Patient Information Form

This is the online Adult New Patient Information Form. If you are filling out this form for your child, please visit this link to access the Child Patient Information Form.

Please note that all of your responses will be encrypted and password-protected when you submit the form. Your responses are confidential and will never be stored on our website.
Adult Patient Information Form

ADULT PATIENT INFORMATION

Name 

Nickname 

Sex: Female  Male 

Age 

Birthdate 

Street Address 

City 

State 

Zip Code 

Email 

Home Phone 

Work Phone

Cell Phone 

Occupation 

Whom may we thank you referring you to our office? 

Please list your hobbies/interests. 

 

RESPONSIBLE PARTY INFORMATION

Person responsible for account 

SSN 

Billing address 

City 

State 

Zip Code 

Relationship to patient 

Date of Birth 

 

EMERGENCY CONTACT

Name 

Relationship 

Address 

City 

State 

Zip Code 

Home Phone 

Work Phone 

Cell Phone 

 

The office of Dr. Brady will be happy to process your orthodontic claims.

To successfully process your claims, all of the following information is necessary.

If you do not have all of the required information we suggest you contact your Human Resources Representative and they can help you with any missing information.

 

DENTAL INSURANCE INFORMATION

Primary Insured's Name 

Insured's Date of Birth 

Insured's SSN 

Insured's Phone Number 

Insurance Company 

Insurance Co. Full Address 

Insured's Employer 

Group No. 

 

DUAL INSURANCE INFORMATION (if applicable)

Secondary Insured's Name 

Insured's Date of Birth 

Insured's SSN 

Insured's Phone Number 

Insurance Company 

Insurance Co. Full Address 

Insured's Employer 

Group No. 

 

 

MEDICAL HISTORY

Physician 

Phone 

Physician's Address 

City 

State

Zip Code 

General Health and Known Illnesses 

Present Medications 

Surgeries (with approximate dates)

Is there a possibility that you may be pregnant? Yes  No 

Have you ever had an allergic reaction to medication? Yes  No 

If Yes, please list the medication(s) 

Have you ever had an allergic reaction to foods; latex; any metals, especially Nickel or Titanium, or any other substance? Yes  No 

If Yes, please list your allergy(ies) to any of the above mentioned 

Have you ever had any of the following:

Bleeding History: Yes  No 

Cancer: Yes  No 

Diabetes: Yes  No 

Hearing Loss: Yes  No 

Epilepsy: Yes  No 

Liver Problems: Yes  No 

High Blood Pressure: Yes  No 

Migraine Headaches: Yes  No 

Stomach Ulcers: Yes  No 

Hepatitis: Yes  No 

Kidney Problems: Yes  No 

AIDS or other immune system disorder: Yes  No 

Cardiovascular disease (heart trouble, heart attack, coronary insufficiency, coronary occlusion arteriosclerosis, stroke): Yes  No 

Damaged heart valves (Mitral valve prolapse, artificial heart valve, heart murmur) or any other conditions which may require you to be premedicated: Yes  No 

If yes to any of the above, does your condition require you to be premedicated? 

 

DENTAL HISTORY

Patient's Dentist 

Date of Last Visit (approx.) 

Dentist's Address 

City 

State 

Zip Code 

Have you previously consulted an orthodontist? Yes  No 

If yes, when and with whom? 

Have you consulted any other dental specialty? Yes  No 

If yes, when and with whom? 

Is there a history of congenitally missing teeth? Yes  No 

Patient  Relative(s) 

Do your gums bleed when you brush your teeth? Yes  No 

Is any part of your mouth sensitive to temperature? Yes  No 

Is any part of your mouth sensitive to pressure? Yes  No 

Have you ever sucked your thumb or finger(s)? Yes  No 

If so, have you stopped this habit? Yes  No 

Do you breathe predominantly through your mouth? Yes  No 

Have you had your tonsils/adenoids removed? Yes  No 

If Yes, when? 

Do you clench or grind your teeth during the day? Yes  No 

Have you been made aware of clenching or grinding your teeth during the night? Yes  No 

Do you now have, or have you ever had, pain in your jaw joint or the sides of your face (in and about the ears)? Yes  No 

Have you ever had clicking or popping in your jaw joint? Yes  No 

If Yes, please explain. 

Have you ever experienced pain when opening wide? Yes  No 

Have you had injury to your jaw? Yes  No 

If Yes, please explain. 

Have you had any injury to your teeth? Yes  No 

If Yes, please explain. 



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Brady Orthodontics

  • Brady Orthodontics - 80 W. Welsh Pool Rd., Suite 203, Exton, PA 19341 Phone: (610) 363-2200 Fax: (610) 594-9360