Skip to content
About Us
Meet Dr. Stoll
Meet The Team
Before and After
Areas Served
Broomfield
Thornton
Westminster
Treatments
Invisalign
How Invisalign Works
Invisalign For Teens
Invisalign For Adults
Smile Express
Braces
Braces for Teens
Braces For Adults
Early Treatment
Resources
Blog
Comfort Instructions
New Patient Info
Technology
Virtual Care
3D Printer
3D Scanner
X-Rays
Retainers for Life
Patient Portal
Contact Us
Menu
About Us
Meet Dr. Stoll
Meet The Team
Before and After
Areas Served
Broomfield
Thornton
Westminster
Treatments
Invisalign
How Invisalign Works
Invisalign For Teens
Invisalign For Adults
Smile Express
Braces
Braces for Teens
Braces For Adults
Early Treatment
Resources
Blog
Comfort Instructions
New Patient Info
Technology
Virtual Care
3D Printer
3D Scanner
X-Rays
Retainers for Life
Patient Portal
Contact Us
(303) 450-2211
New Adult Patient Information Form
1
Patient Information
2
Emergency Information
3
Insurance Information
4
Dental History
5
Medical History
6
Acknowledgement
Are you an adult patient (18 years of age or older)?
(Required)
Yes
No
Patient Name
(Required)
Sex
(Required)
Male
Female
Date of Birth
(Required)
MM slash DD slash YYYY
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Primary Phone
Phone Type
Home
Cell
Other
Email Address
(Required)
Employer's Name
Marital Status
Single
Married
Divorced
Widowed
Significant Other
Spouse/Partner's Name
Emergency Contact Name
Phone Number
Relation to You
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Primary Insurance
Primary Insurance Company
Phone
Primary Group Number
Primary Policy Number
Primary Member ID Number
Primary Policy Holder's Name
Relation To You
Primary Policy Holder's Social Security Number
Primary Policy Holder's Date of Birth
MM slash DD slash YYYY
Primary Policy Holder's Employer
Secondary Insurance
Insurance Company Name
Phone
Group Number
Policy Number
Member ID Number
Policy Holder's Name
Relation To You
Policy Holder's Social Security Number
Policy Holder's Date of Birth
MM slash DD slash YYYY
Policy Holder's Employer
General Dentist
Date of Last Visit
MM slash DD slash YYYY
How did you hear about our Practice?
AD
Social Media
Online Search
Referral
Physician
Other
Name of Person Referring
What are the main concerns you would like orthodontics to accomplish?
Have you visited an orthodontist before?
Yes
No
Date of Visit
MM slash DD slash YYYY
Reason For Visit
Have your tonsils or adenoids been removed?
Yes
No
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Yes
No
Have you ever had an injury to (Select all that apply):
None
Teeth
Mouth
Chin
Do you have speech problems?
Yes
No
If Yes, please explain:
Do your gums bleed?
Yes
No
Do you smoke?
Yes
No
Do you like your smile?
Yes
No
Do you currently or have you ever had any of the following habits?
None
Clenching/Grinding Teeth
Lip Sucking/ Biting
Mouth Breathing
Nail Biting
Thumb/Finger Sucking
Chewing/ Eating Problems
Pacifier Usage
Are you currently being treated by a physician?
Yes
No
Reason
Do you have any allergies/ sensitivities to medications or latex?
Yes
No
Please list allergies
Are you currently taking any prescription or over-the-counter medications?
Yes
No
Please list medications and dosages:
Have you had any serious illnesses or operations?
Yes
No
Please describe:
Are you pregnant?
Yes
No
Check if you have or have ever had any of the following:
None
Abnormal Bleeding
Anemia
Arthritis/Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back Problems
Blood Disease
Blood Transfusion
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Congenital Heart Defect
Cortisone Treatments
Cough, Persistent
Coughing Blood
Diabetes
Difficulty Breathing
Drug/Alcohol Abuse
Epilepsy
Emphysema
Fainting
Fever Blisters/Herpes
Glaucoma
Headaches
Heart Attack
Heart Surgery
Heart Murmur
Heart Problems
Hemophilia
Hepatitis
High Blood Pressure
High/Low Blood Sugar
HIV/AIDS
Hospitalized for Any Reason
Jaw Pain
Kidney Disease
Liver Disease
Mitral Valve Prolapse
Pacemaker
Psychiatric Problems
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shingles
Shortness of Breath
Sickle Cell Disease/Traits
Sinus Problems
Skin Rash
Stroke
Swelling of Feet or Ankles
Thyroid Problems
Tobacco Habit
Tonsillitis
Tuberculosis
Ulcer
Venereal Disease
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.
I agree
I disagree
Signature of Patient/Responsible Party
Today
MM slash DD slash YYYY