15230 Levan Road, Across from St Mary Hospital. Livonia, MI 48154
Adult New Patient Form - Masri Orthodontics : Get the Smile You Deserve

Adult New Patient Form

Former Address (if less than 3 years)

YesNo

SingleMarriedDivorcedWidowedSeparated

YesNo


NoYes

Medical Information

GoodFairPoor

NoYes

NoYes

Ear infectionsColdsSore throats
AsthmaDiabetes RheumaticBone DisordersEpilepsyGlaucomaAnemiaHepatitisBlood diseaseAIDS/HIVHeart diseaseFeverAllergies

Dental Information:

YesNo


YesNo

NoYes

TMJGum disease

YesNo

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes


NoYes


NoYes

GoodFairPoor

YesNo

YesNo

QualityEstheticsCostDiscomfortTime
Crooked teethCrowdingClose spacesCrossbiteJaw painHeadachesDon't like smileCosmeticsOverbiteBad biteHard to chewCan't close mouth
Mouth BreathingThumb suckingNail/Lip bitingSnoringLeaning on chin or faceGrinding of teeth

About your home care

Agree To Terms

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in patient's medical status. I also authorize the dental staff to perform the necessary orthodontic services as needed. I further authorize that photos taken during treatment may be used in journal articles or promotional materials and are the property of Dr. Masri. I understand that where appropriate, credit bureau reports may be obtained.

Yes, I agree to the above terms & conditions.