Medford Office

30 Jackson Road, Suite B2
Medford, NJ 08055

Euksuzian Orthodontics Medford Office

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About Us
Our Patients Feedback
New Patients
Blog
Braces 101
Treatment
Contact

New Patient Form

Home > New Patients > New Patient Form

Thank you for your interest in our services. Please fill out the information below and one of our team members will contact you to schedule an appointment time. We look forward to seeing you soon.

New Patient Form

We would love to hear from you! Please fill out this form and we will get in touch with you shortly.

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Patient Information
Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Phone
Birth Date
MM slash DD slash YYYY
Age
Email
School
Grade
Siblings / Children
If patient is a minor, give parent's or guardian's name.
How did you hear of our office?

RESPONSIBLE PARTY INFORMATION
Name
First Last
Marital Status
Address
Street Address City State / Province / Region ZIP / Postal Code Country
How long at this address
Home Phone
Work Phone
Social Security #
Birth date
MM slash DD slash YYYY
Relationship to Patient
Employer
Occupation
Number Years Employed
Spouse's Name
First Last
Relationship to Patient
Employer
Occupation
Number Years Employed
Social Security #
Birth date
MM slash DD slash YYYY
Work Phone

INSURANCE INFORMATION
Insured's Name
Insured's Employer
Insurance Company
Group Number
Local Number
Insurance Company Address
Street Address City State / Province / Region ZIP / Postal Code Country
Insurance Phone Number
Do you have dual coverage?
- Yes
- No

MEDICAL HISTORY
Family Physician
Phone
Date of Last Visit
MM slash DD slash YYYY
Are you taking any medication?
- Yes
- No
Are you allergic to any medications?
- Yes
- No
Do you have a history of a major illness?
- Yes
- No
Have you had any major operations?
- Yes
- No
Have you ever been involved in a serious accident?
- Yes
- No

Have you ever had any of the following diseases or medical problems
Abnormal Bleeding / Hemophilia
- Yes
- No
Anemia
- Yes
- No
Arthritis
- Yes
- No
Asthma or Hayfever
- Yes
- No
Congenital Heart Defect
- Yes
- No
Nervous Discorders
- Yes
- No
Diabetes
- Yes
- No
Dizziness
- Yes
- No
Asthma or Hayfever
- Yes
- No
Epilepsy
- Yes
- No
Gastrointestinal Disorders
- Yes
- No
Heart Problems
- Yes
- No
Heart Murmur
- Yes
- No
Hepatitis / Liver Problems
- Yes
- No
Herpes
- Yes
- No
High Blood Pressure
- Yes
- No
HIV + / AIDS
- Yes
- No
Kidney Problems
- Yes
- No
Nervous Disorders
- Yes
- No
Pneumonia
- Yes
- No
Prolonged Bleeding
- Yes
- No
Radiation / Chemotherapy
- Yes
- No
Rheumatic Fever
- Yes
- No
Tuberculosis
- Yes
- No
Tumor or Cancer
- Yes
- No
Bone Disorders
- Yes
- No
Are there any medical conditions we have not discussed that you feel we should be aware of?

PATIENT DENTAL HISTORY
General Dentist
Date of Last Visit
MM slash DD slash YYYY
Dentist Phone Number
What Concerns you most about your teeth?
Are you presently in any dental pain?
- Yes
- No
Have you ever experienced any unfavorable reaction to dentistry?
- Yes
- No
Have you ever lost or chipped any teeth?
- Yes
- No
Have there been any injuries to face, mouth or teeth?
- Yes
- No
Is any part of your mouth sensitive to temperature or pressure?
- Yes
- No
Do your gums bleed when you brush?
- Yes
- No
Are you presently in any dental pain?
- Yes
- No
Do you have any type of thumb or tongue habit?
- Yes
- No
Are you presently in any dental pain?
- Yes
- No
Are you a mouth breather?
- Yes
- No
Have you ever seen an orthodontist?
- Yes
- No
Has anyone in the family received orthodontic treatment?
- Yes
- No
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
- Yes
- No
Are you aware of your jaw clicking or popping?
- Yes
- No
Are you aware of clenching your teeth during the day?
- Yes
- No
Have you ever been told that you grind your teeth?
- Yes
- No
Do you have "tension" headaches?
- Yes
- No
Have you ever experienced chronic ringing in your ears ?
- Yes
- No
Are you aware some appointments will be during school / work hours?
- Yes
- No

Euksuzian Orthodontics
30 Jackson Road, Suite B2
Medford, NJ 08055 (609) 654-0600

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Medford Office

Euksuzian Orthodontics: Sarkis Euksuzian DMD, PA

30 Jackson Road, Suite B2
Medford, NJ 08055

Hours

Monday 8:30am - 5:30pm
Tuesday 9am - 8:30pm
Wed-Fri 8:30am - 5:30pm

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