How do I get started?

Please fill out the following information, and submit the form prior to your New Patient consultation.  We will  have all of the paperwork ready for you when you arrive at our office (and the good news is... no more clipboards).  If you would like, you may print out the completed form and bring it in with you.  Our New Patient Coordinator looks forward to assisting you, and will be with you throughout your New Patient consultation.

Thank you for choosing Dr. Richard Crowder D.D.S.

Orthodontic Specialist

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We have made every effort to keep private information such as S.S. # out of this form.  If you would rather fax the completed information to us, please print out the form and Fax it to 316-684-5197.

 

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Patient Information

First Name
Last Name
Preferred Name
Date of Birth
Age
Sex	Male Female
Address
Address (cont.)
City
State
Zip/Postal Code
Home Phone
Father's Name
Mother's Name

Responsible Party Information

Please provide the following Responsible Party information:

First Name
Last Name
Street Address
Address (cont.)
City
State
Zip/Postal Code
Work Phone
Home Phone
FAX
E-mail
Relation to Patient
Do you have  Dental Insurance	Yes   No
Patient's Family Dentist

MEDICAL HISTORY

Is patient in good health?

Yes No

Does patient have any history of major illness?

Yes No

If yes, please explain:

Has Patient had any past surgeries

Yes No

If yes, please explain:

Does the patient have tendency to colds? Sore throats? Ear infections?

Yes No

Have tonsils and adenoids been removed?

Yes No

Physicians Name:

List any medications now being taken.

Allergies

Do you need to be pre-medicated?

Yes No

CHECK ANY OF THE FOLLOWING FOR WHICH PATIENT HAS BEEN TREATED

PATIENTS DENTAL HISTORY

Have there ever been any injuries to the face, mouth or teeth?

Yes No

Have you ever sucked your fingers or thumb?

Yes No

Do you have any speech problems?

Yes No

Are you a mouth breather                While awake?                While asleep?

Yes No                           Yes No                  Yes No

Have you been informed of any missing or extra permanent teeth?

Yes No

Have you consulted an orthodontist previously?

Yes No

Did either parent have orthodontic treatment?

Yes No

Do you have pain in the jaw joints?

Yes No

If yes, when did this begin?

Do you have popping or cracking of the jaw joints?

Yes No

If yes, when did this begin?

Last appointment with a general dentist:

Purpose:

INSURANCE INFORMATION

Please provide your insurance card when you arrive at our office, so that we may fill out the paperwork for you and have your pre-determination mailed to you.  If you prefer, you may bring a copy of your insurance card (BOTH FRONT AND BACK) for us to keep.  We file your insurance electronically, which in most cases means you will have a response within days not weeks.

APPOINTMENT SCHEDULE

We will make every effort to schedule your appointment at the most convenient time.  We have appointments available throughout the day starting as early as 7:15 a.m. on some days, and going as late as 3:30 p.m. on others.  We must make these appointments around Dr. Crowder's schedule, in order to allow you the patient the most time with Dr. Crowder.  Please come with any questions you may have.  We believe that it is important to feel comfortable with your Dr., and we want you to leave our office happy about your decision to have treatment with us.

If you have not yet scheduled your appointment, please tell us which time of day  will be more convenient for you so that we may call you with our availabilities.  New patient appointments last approx. 45 minutes.

Morning (7:15 - 10:15)    Afternoon (1:30 - 3:30)   

First Available    Appointment Scheduled

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