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Los Angeles: 11620 Wilshire Blvd. Suite 440, Los Angeles, CA 90025
|
Woodland Hills: 5350 Topanga Canyon Blvd, Woodland Hills, CA 91364

ABOUT US
TREATMENTS
NEW PATIENTS
BLOG
CONTACT US
AREAS WE SERVE

Call Us Now Book Online

Current Patients:
(310) 444 1113
New Patients:
(310) 929-6220

ADULT PATIENT FORMS

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

NEW PATIENT FORM

Step 1 of 6 - Personal Information

16%

Personal Information
Title*
- Mr.
- Mrs.
- Ms.
- Dr.
Full Name*
First Name Last Name
Social Security Number
Date of Birth*
Married?
- Yes
- No
Spouse's Full Name
Spouse’s First Name Spouse’s Last Name
Home Address
Street Address Address Line 2 City State ZIP Code
Do you
- Own
- Rent
How long have you been at current residence?
Contact Info
Home Phone Number
Cell Phone
E-mail Address*
Who may we thank for referring you?
Work Info
Employer
Business Phone
How long have you been employed with current employer?
Work Address
Street Address Address Line 2 City State ZIP Code

Medical History
Physician’s Full Name
Physician’s First Name Physician’s Last Name
Medical ID Number
Physician’s Address
Street Address Address Line 2 City State ZIP Code
Please answer the following questions:
Have you undergone a physical exam in the past year?
- Yes
- No
Are you presently under a physician’s care?
- Yes
- No
Have you ever had a major surgery?
- Yes
- No
Have you ever been hospitalized?
- Yes
- No
Are you taking any pills, medications or drugs?
- Yes
- No
Are you allergic to novocain or penicillin?
- Yes
- No
Have you had any unusual reaction to any medication?
- Yes
- No
Have you had tonsils and/or adenoids removed?
- Yes
- No
Do you have fainting or dizzy spells?
- Yes
- No
Do you have too high or too low blood pressure?
- Yes
- No
Are you HIV Positive?
- Yes
- No
Have you ever been diagnosed or treated for the following?
Heart Problems
- Yes
- No
Heart Murmur
- Yes
- No
Kidney Problems
- Yes
- No
Lung Problems
- Yes
- No
Liver Problems
- Yes
- No
Allergies
- Yes
- No
Diabetes
- Yes
- No
Epilepsy
- Yes
- No
Anemia
- Yes
- No
Arthritis
- Yes
- No
Hepatitis
- Yes
- No
Rheumatic Fever
- Yes
- No
Emotional Problems
- Yes
- No
Malignancies
- Yes
- No
Endocrine Problems
- Yes
- No
Bone Problems
- Yes
- No
Prolonged Bleeding
- Yes
- No
Tuberculosis
- Yes
- No
Asthma
- Yes
- No
AIDS or ARC
- Yes
- No
Are there any other medical problems we should be aware of?
- Yes
- No
If Yes, Please Explain

Dental History
Dentist's Full Name
Dentist’s First Name Dentist’s Last Name
Dentist’s Phone
Date of Last Cleaning
Any Pending Work?
Dentist’s Address
Street Address Address Line 2 City State ZIP Code
Please answer the following questions:
Have you ever had previous orthodontic consultation or treatment?
- Yes
- No
Have you been informed of any extra or missing teeth?
- Yes
- No
Have any permanent teeth been removed by extraction?
- Yes
- No
Has any family member had orthodontic treatment?
- Yes
- No
If so who?
Have you ever sucked your thumb or finger?
- Yes
- No
Do you breath predominantly through the mouth?
- Yes
- No
Do you have any speech problems?
- Yes
- No
Do you grind or clench your teeth?
- Yes
- No
Do you have pain or clicking of the jaw joint?
- Yes
- No
Have any teeth been injured or chipped due to an accident?
- Yes
- No
Have you ever had pain in the face or head?
- Yes
- No
Have you ever had severe jaw or head injury?
- Yes
- No
Do your gums bleed on brushing or flossing?
- Yes
- No
Are you concerned about the appearance of your teeth?
- Yes
- No
Do you want your teeth straightened?
- Yes
- No
Are there any other dental/orthodontic problems we should be aware of?

Insurance Information
Patient Initials
Date
Insured's Full Name
Insured’s First Name Insured’s Last Name
Insured’s SSN or IDN
Insured's Employer
Insurance Company
Insurance Phone Number
Insurance Address
Street Address Address Line 2 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
Relative's First Name Relative's Last Name
Relative's Phone Number
Relative's Address
Street Address Address Line 2 City State ZIP Code

Notice of Privacy Practices*
- I acknowledge that I have read the Notice of the Privacy Practices of Atoosa Nikaeen Orthodontics
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MAKE AN APPOINTMENT

After you are done filling out the patient form, then call (310) 444-1113 or email us to schedule a free initial consultation in Los Angeles, Beverly Hills, and Santa Monica.

Current Patient: (310) 444-1113
New Patients: (310) 929-6220
info@invisibraces.com
11620 Wilshire Blvd. Suite 440,
Los Angeles, CA 90025

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