Online Forms | Orthodontist in Glastonbury, CT

Orthodontic Treatment
- Invisalign®
- Braces
  - Ceramic Braces
Patient Resources
Orthodontic Technology
About Us
Contact

Menu

Orthodontic Treatment
- Invisalign®
- Braces
  - Ceramic Braces
Patient Resources
Orthodontic Technology
About Us
Contact

Orthodontic Treatment
- Invisalign®
- Braces
  - Ceramic Braces
Patient Resources
Orthodontic Technology
About Us
Contact

Menu

Orthodontic Treatment
- Invisalign®
- Braces
  - Ceramic Braces
Patient Resources
Orthodontic Technology
About Us
Contact

88 Citizens Drive,
Glastonbury, CT 06033

860-633-8321

Request In-Office Consultation

Request Virtual Consultation

860-633-8321

88 Citizens Drive, Glastonbury, CT 06033

Request Virtual Consultation

Request In-Office Consultation

Orthodontic Treatment
- Invisalign®
- Braces
  - Ceramic Braces
Patient Resources
Orthodontic Technology
About Us
Contact

Menu

Orthodontic Treatment
- Invisalign®
- Braces
  - Ceramic Braces
Patient Resources
Orthodontic Technology
About Us
Contact

A stretched-out grey semicircle.

Request In-Office Consultation

Request Virtual Consultation

Patient Form

Step 1 of 6

16%

Patient Information

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

Gender(Required)

Preferred Name

Grade

Home Phone

Address(Required)

Street Address Address Line 2 City State ZIP Code

Cell Phone(Required)

Email(Required)

School

Interests

Is the patient a minor?

Yes

No

Name/Relationship of person accompanying patient to today's appointment

Patient lives with whom/relationship

Who has legal custody of patient?

Name of siblings & ages

Responsible Party

Name(Required)

First Last

Marital Status

Cell Phone(Required)

Work Phone

Home Phone

Email(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Social Security Number

Address(Required)

Street Address Address Line 2 City State ZIP Code

Employer(Required)

Occupation

Spouse's Name/Other Parent

First Last

Relationship to Patient

Social Security Number

Date of Birth

MM slash DD slash YYYY

Cell Phone

Work Phone

Primary Insurance Information

Employeer(Required)

Policy ID Number(Required)

Insurance Company(Required)

Group Number(Required)

Insurance Company Address(Required)

Insurance Phone Number(Required)

Subscriber(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Relationship to Patient(Required)

In case of emergency, please contact(Required)

Phone(Required)

How did you you choose Risinger Orthodontics?

CHECK ALL THAT APPLY

How did you choose Risinger Orthodontics?

Google

Bing/Yahoo

Facebook

Instagram

Nextdoor

School Sponsorship

Print Article or Flyer

Magazine Ad

Direct Mail

Radio

Billboard

Event

Family/Friend (fill space below)

Dentist/Doctor (fill space below)

Other (fill space below)

Please Describe:

PLEASE READ

We are passionate about our mission to give everyone a beautiful smile. Please help us to help you and your child by letting us know of any delayed development, social disabilities, ADD or ADHD, Bipolar, Autism, etc.

Medical History

Physician(Required)

Phone

Date of Last Exam

MM slash DD slash YYYY

Please check all that apply

The patient...

Is currently under medical treatment

Has been hospitalized for any surgical operations or serious illness in the past five years

Is taking medication(s) including non-prescription medicine

Is using tobacco

is allergic medications or substances, including metals

is pregnant

has taken bisphosphonates (ex. Fosamax) for osteoporosis

is allergic to latex

has not reached puberty

Please use this space for any explanation.

Please check all that apply:

Has fever/allergies

Cold sores

Migraines

Diabetes/glaucoma

Rheumatic fever

AIDS or HIV infection

Cardiac pacemaker

Asthma (inhaler)

Fainting/seizures

Thyroid problem

High/low blood pressure

Heart trouble

Epilepsy/convulsions

Removal of Adenoids/tonsils

Leukemia

Kidney/liver disease

Anemia

Cancer

Joint replacement/implant

Hepatitis/jaundice

Stomach troubles/ulcers

Sinus problems

Stroke

Radiation therapy

Respiratory problems

Bone disorder

Osteopenia/osteoporosis

Dental History

Dentist

Date of Last Cleaning

MM slash DD slash YYYY

Please check all that apply.

The patient...

is anxious or nervous about dental treatment

feels pain in their teeth

has sores or lumps in or near the mouth

has had a head, neck or jaw injury

has chronic jaw clicking/popping

clenches or grinds their teeth

bites lips or cheeks frequently

has had speech therapy

has outstanding dental work to be completed

has not had instruction on the correct method of brushing and flossing teeth

bites their nails

sucks their thumb

tongue thrusts while swallowing

breathes through mouth

Please use this space for any explanation.

How many times a day do you brush?(Required)

Please check the boxes below which describe the problem(s) for which you are seeking treatment:

Crowding

Extra space

Teeth stick out too far

TMJ problems

Poor bite relationship

Missing teeth

Extra permanent teeth

Teeth erupting in the wrong position

Other

If other, please describe

Has the patient had an orthodontic evaluation or treatment before?(Required)

Yes

No

If so, when and by whom?

Do you have a preference of braces or Invisalign?(Required)

Authorization and Release

TO THE BEST OF MY KNOWLEDGE THE ABOVE QUESTIONS HAVE BEEN ANSWERED ACCURATELY. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM THIS OFFICE OF ANY CHANGES TO THE PATIENT’S MEDICAL STATUS. I GIVE RISINGER ORTHODONTICS PERMISSION TO PERFORM THE NECESSARY DENTAL SERVICES THAT THE PATIENT MAY NEED.

Consent

By checking this box you agree to the above mentioned consent statement.

Date(Required)

MM slash DD slash YYYY

Typed Name/Signature(Required)

First Last

Relationship to Patient(Required)

For Office Use

Doctor Signature

Doctor Comments

Upon successful submission this page will be redirected.

Facebook-f Google Yelp Instagram

Tel: 860-633-8321 | 88 Citizens Drive, Glastonbury, CT 06033

© Copyright 2021 Risinger Orthodontics. All Rights Reserved. | Privacy Policy | Terms of Use