11620 Wilshire Blvd. Suite 440, Los Angeles, CA 90025
(310) 444-1113
Atoosa Nikaeen, D.D.S website logo

New Orthodontic Forms for Patients in Los Angeles, Santa Monica, Beverly Hills

Save up to 30 minutes at your first visit by completing our online Patient Registration and Health History forms from the convenience of your own home.

Personal Information
Mr. Mrs. Ms. Dr.

First Name: Middle Name:
Last Name:

Social Security # Date of Birth:
Married? yes no

Spouse’s First Name Spouse’s Last Name
Spouse’s Occupation

Home Address

Street City
State

 

Zip Code

Do you own rent other

How long have you been at current residence

Contact Info
Home Phone Number Cell Phone E-mail Address

Work Info
Employer Business Phone
How long have you been employed with current employer

Work Address
Street City
State

 

Zip Code

Medical History

Physician’s First Name Physician’s Last Name
Physician’s Phone Date of Last Visit
Medical ID Number

Physician’s Address
Street City
State

 

Zip Code

Please answer the following questions:
yes
no
Have you undergone a physical exam in the past year?
Are you presently under a physician’s care?
Have you ever had a major surgery?
Have you ever been hospitalized?
Are you taking any pills, medications or drugs?
Are you allergic to novocain or penicillin?
Have you had any unusual reaction to any medication?
Have you had tonsils and/or adenoids removed?
Do you have fainting or dizzy spells?
Do you have too high or too low blood pressure?
Are you HIV Positive?
Have you ever been diagnosed or treated for the following?
yes
no
yes
no
Heart Problems
Hepatitis
Heart Murmur
Rheumatic Fever
Kidney Problems
Emotional Problems
Lung Problems
Malignancies
Liver Problems
Endocrine Problems
Allergies
Bone Problems
Diabetes
Prolonged Bleeding
Epilepsy
Tuberculosis
Anemia
Asthma
Arthritis
AIDS or ARC
Are there any other medical problems I should be aware of?

IF YES, PLEASE EXPLAIN
Dental History

Dentist’s First Name Dentist’s Last Name
Dentist’s Phone Date of Last Cleaning
Any Pending Work?

Dentist’s Address
Street City
State

 

Zip Code

What is your major concern about your teeth?

Please answer the following questions:
yes
no
Have you ever had previous orthodontic consultation or treatment?
Have you been informed of any extra or missing teeth?
Have any permanent teeth been removed by extraction?
Has any family member had orthodontic treatment?
if so who?
Have you ever sucked your thumb or finger?
Do you breath predominantly through the mouth?
Do you have any speech problems?
Do you grind or clench your teeth?
Do you have pain or clicking of the jaw joint?
Have any teeth been injured or chipped due to an accident?
Have you ever had pain in the face or head?
Have you ever had severe jaw or head injury?
Do your gums bleed on brushing or flossing?
Are you concerned about the appearance of your teeth?
Do you want your teeth straightened?
Are there any other dental/orthodontic problems I should be aware of?

Patient Initials Date

Insurance Information
Insured’s Name Insured’s SSN or IDN
Insured Employer Insurance Company
Insurance Phone Number

Insurance Address
Street City
State

 

Zip Code

Group Number Local Number
Do you have orthodontic coverage? yes no

If yes, benefit amount:

If you have secondary insurance
Insured First Name Middle Name
Last Name Social Security #
Insured’s Employer
Insurance Company
Insurance Phone Number
Insurance Address
Street City
State

 

Zip Code

Group Number Local Number
Do you have orthodontic coverage?yes no
If yes, benefit amount:

Emergency Information
Name of nearest relative not living with you
First Name Middle Name
Last Name

Complete Address
Street City
State

 

Zip Code

Phone Number

Notice of Privacy Practices
Please take a moment to read our Notice of Privacy Practice
I, , acknowledge that I have received and read a Notice of the Privacy Practices of Atoosa Nikaeen Orthodontics.
Signature of Patient or Guardian:
Relationship to Patient if Guardian or Representative:
Enter the security code:CAPTCHA Image

 

Please call us at (310) 444-1113 or send an email to schedule your free initial consultation. We serve Southern California including Los Angeles (LA), Beverly Hills, and Santa Monica.

We look forward to hearing from you!