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Queens
36-16 Main St, Suite 802, Flushing, NY 11354
Manhattan
77 Bowery, 6th Fl, New York, NY 10002
212-274-0477
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Home
Office Info
About Us
Directions to MBO
Frequently Asked Questions
Our Orthodontists
Dr. Jenny Zhu
Dr. Victor Chiang
Dr. Kimberly Bui
Dr. Mythilee Kugathasan
Treatment Options
Clear Aligners
Braces
Phase 1 Early Treatment
Orthodontic Retainers
Before and After
Overbite
Crowded Teeth
Open Bite
Underbite
Crossbite
Gap Teeth
Phase 1
Videos & Articles
Schedule Appointment
Home
Office Info
About Us
Directions to MBO
Frequently Asked Questions
Our Orthodontists
Dr. Jenny Zhu
Dr. Victor Chiang
Dr. Kimberly Bui
Dr. Mythilee Kugathasan
Treatment Options
Clear Aligners
Braces
Phase 1 Early Treatment
Orthodontic Retainers
Before and After
Overbite
Crowded Teeth
Open Bite
Underbite
Crossbite
Gap Teeth
Phase 1
Videos & Articles
Schedule Appointment
Patient Registration Form
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Responsible Party Information
If the patient is under age 18, legal guardian consent is required.
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How Did You Hear About MBO?
Check all referral sources
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Other Sources
Please provide referring dentist or doctor information.
Please provide name of referring friend or family referrer so we can properly thank them!
Please provide any other sources of referral to MBO.
What is the reason for your visit?
Smile improvement
Dental health improvement
Profile improvement
Bite issues
Crowding
Spacing
Jaw pain
Orthodontic retention
Other
Please explain in more detail
What appliance do you prefer?
Clear Aligners
Braces
Dental Insurance Information
Do you have dental insurance?
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Insurance Company
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Subscriber Full Name
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Subscriber Date of Birth
*
mm/dd/yyyy
Relationship to Patient
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Self
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Subscriber ID or SSN
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Group Number (Optional)
Additional Insurance Information or Notes
Submit and Review Health and Dental History
Health History
Has there been a major change to your health within the past year?
Yes
No
If yes, please explain:
Are you pregnant?
Yes
No
If yes, please provide estimate due date:
Do you have any artificial joints, heart valves, implants, or prosthesis?
Yes
No
If yes, please explain:
Are you currently taking any prescription or over-the-counter medications?
Yes
No
If yes, please list reason and dosage:
Do you have any allergies?
Yes
No
If yes, please list:
Are you receiving ongoing medical care?
Yes
No
If yes, please explain:
Please select all that applies to you:
AIDS / HIV
Anemia
Anxiety
Arthritis
Artificial Heart Valves
Asthma
Chest Pain
Colitis
Depression
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Fainting Spells
Hay Fever
Heart Attack
Heart Murmurs
Heartburn
Hemophilia
Hepatitis A, B, or C
High Blood Pressure
Jaundice
Joint or Back Pain
Liver Disease
Persistent Cough
Seasonal Allergies
Shortness of Breath
Stomach Pain
Stroke
Thyroid Problems
Tuberculosis
Ulcers
Please any other known disease or medical conditions not stated above:
Date of your last medical visit or check up:
mm/dd/yyyy
Physician’s Name and Contact Information:
Dental History
Do you need to be pre-medicated prior to dental treatment?
Yes
No
If yes, please explain:
Have you ever seen an orthodontist or had prior orthodontic treatment?
Yes
No
If yes, please explain:
Do you experience clicking in your jaw?
Yes
No
If yes, please explain:
Do you clench your jaw or grind your teeth?
Yes
No
If yes, please explain:
Do you have a nail biting habit?
Yes
No
If yes, please explain:
Do you have a thumb sucking habit?
Yes
No
If yes, please explain:
Do you have a mouth breathing habit?
Yes
No
If yes, please explain:
How often do you brush your teeth?
2 or more times a day
1 time per day
1 time per week
1 time per month
Very Rarely
Never
How often do you floss your teeth?
2 or more times a day
1 time per day
1 time per week
1 timer per month
Very Rarely
Never
Do you smoke tobacco or any other substance?
2 or more times a day
1 time per day
1 time per week
1 time per month
Very Rarely
Never
Do you have any current or past history of substance abuse?
Yes
No
If yes, please explain:
Date of your last dental visit:
mm/dd/yyyy
General Dentist’s Name and Contact Information:
I understand that, to the best of my knowledge, all of the above answers are true and correct. If I ever have any change in my health or medications, I will inform my health care provider immediately. I hereby give my consent to treatment for myself, or the named patient of whom I am the parent or legal guardian, to Manhattan Bridge Orthodontics.
Relationship to Patient
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Date
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Please clarify your relationship to the patient
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Upon submission of this form, you will be directed to review our notice of privacy practices and your health information rights.
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