WILMINGTON ORTHODONTIC CENTER

Adult information

 

Tell us about you.

Your email adress* *
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Select a Choice *
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Full Name: *
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I preferred to be called:
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Who referred you to us? *
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Birthdate: *
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Gender *
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Street Address *
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Address line 2 *
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City *
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State / Province / Region *
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Postal / Zip code *
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Country *
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Email: *
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Phone Number: *
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Cell Phone Number: *
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Where and when is the best way to reach you?
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Marital Status *
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Occupation:
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Employer:
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Employer Street Address *
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Address line 2 *
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City *
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State / Province / Region *
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Postal / Zip code *
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Country *
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Work Phone Number *
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Spouse: *
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Spouses Occupation: *
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Spouses Employer: *
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Phone Number *
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In the case of an emergency, who should we contact? *
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Name and surname *
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Work Phone Number: *
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Home Phone Number: *
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Cell Phone Number: *
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DENTAL INFORMATION
Please provide information on the last dentist you have seen:
Name *
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Phone Number *
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Date range seen: *
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Type of treatment: *
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What is the primary reason you came to our office today?
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Are you currently experiencing pain/discomfort? *
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Current dental health

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Does food catch between your teeth? *
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Are you teeth sensitive to cold or sweets? *
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Any unpleasant experiences in a dental office? *
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If yes, please explain:
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Do you have dental insurance? *
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Are your teeth somewhat yellowed, darkened, or stained? *
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Have you ever experienced pain or discomfort in your jaw joint? (TMJ/TMD) *
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Are there any spaces between your teeth? *
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Do you grind your teeth or are any of the biting edges on your teeth chipped or worn down? *
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Do you have a "gummy" smile-showing too much gum tissue or have gums that are too thick? *
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Are you teeth sensitive to cold or sweets? *
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Are your gums red, puffy, or fo they bleed? *
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Do you have any grey, black, or silver (mercury) dental fillings in your teeth that you want to replace? *
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Do you have any old crowns that have dark edges at the top or that don't really look natural? *
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Do you smoke? *
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If yes, how much?
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Do you drink alcohol? *
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If yes, how much?
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AUTHORIZATION
I authorize the relase of medical and dental information to insurance carriers and to other healthcare providers involved in the care of this patinet and the use of records by Dr. Pancko for teaching purposes and scientific publication. Please advise Dr. Pancko of any changes in your childs medical or dental health while under the care of our office. I hereby authorize Dr. Pancko to obtain credit reports if necessary.
Date *
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Name *
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SMILE GALLERY

Testimonials

With so many great choices in the area for a good orthodontist, we searched and searched for the best fit and are so glad we found Dr. Pancko. The doctor is so wonderful, instantly giving us the feeling that our son is in good medical hands with a qualified and knowledgeable orthodontist.

Dave Marcus