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About
New Patients
Treatment Options
Blog
Contact
- Our Location
- Request An Appointment

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Home
About
New Patients
Treatment Options
Blog
Contact
- Our Location
- Request An Appointment

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ABOUT

About Dr. Tuncay
Meet the Team
Testimonials
Write Us a Review
FAQ

NEW PATIENTS

First Visit
Easy Financing
Why Choose Bespoke Braces

ORTHODONTICS

All About Braces
All About Aligners
Incognito
Adolescent Orthodontics
Adult Orthodontics
Retainers
BRIUS
INBRACE Lingual Braces

ACCELERATED TREATMENT

AcceleDent
BRIUS
INBRACE Lingual Braces
OrthoPulse
Propel
SureSmile

INVISALIGN

Invisalign Info
Invisalign Teen
Cost of Invisalign
Vivera

CONTACT

Our Location
Request An Appointment

Patient Information

Name *

First

Middle

Last

Address

Address Line 1

City

State

Zip Code

Phone

Birthdate//

Marital Status

Dropdown

If patient is a minor, parent/guardian's name

Name and ages of siblings

Email *

Whom may we thank for referring you to your office?

Sports/Hobbies/Musical Instruments

School/Occupation

Grade

Nickname

Person Responsible for Account

Same as above?

Yes
No

Relationship to Patient

Have you been at this address for more than three years?

Yes
No

Work Phone

Cell Phone

Social Security #

Employer

Occupation

Number of years employed

Dental Insurance Information

Insured's Name *

First

Middle

Last

Insured's Employer

Insured's Birthdate

Social Security #

Insurance Company

Group #

Phone

Subscriber/Employer ID #

Insurance Company's Address

Address Line 1

City

State

Zip Code

Do you have dual coverage?

Yes
No

Insured's Name (2) *

First

Middle

Last

Insured's Employer (2)

Insured's Birthdate (2)

Social Security # (2)

Insurance Company (2)

Group # (2)

Phone (2)

Subscriber/Employer ID # (2)

Insurance Company's Address (2)

Address Line 1

City

State

Zip Code

Emergency Information

Name of nearest relative not living with you *

First

Middle

Last

Relationship

Cell or Phone

Address

Address Line 1

City

State

Zip Code

What are the main concerns that you would like orthodontics to address?

Please describe concerns

Has the patient ever been evaluated for or had orthodontic treatment before?

Yes
No

Have there been any injuries to the face, mouth, teeth or chin?

Yes
No

How does the patient feel about wearing orthodontic appliances?

Have adenoids or tonsils been removed?

Yes
No

Has the patient been informed of any missing or extra permanent teeth?

Yes
No

Has the patient ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?

Yes
No

Does the patient brush his/her teeth daily?

Yes
No

Floss his/her teeth daily?

Yes
No

Patient's Dentist *

Dentist's Number

Date of Last Visit (Dentist)

Patient's Physician *

Physician's Number

Date of Last Visit (Physician)

Is the patient currently under the care of a physician?

Yes
No

Has puberty begun?

Yes
No

If yes, when?

Please describe the patient's current physical health

Do you take or have you taken an osteoporosis medication?

Yes
No

Please list all drugs that the patient is currently taking

Please list all allergies (drugs, foods, other)

Has the patient ever had any of the following medical problems?

Check the box, if yes.

Abnormal Bleeding

ADD/ADHD

Sleep Apnea

Allergy to Latex/Metals

Allergy to Plastic

Any Hospital Stays

Any Operations

Asthma

Cancer

Congenital Heart Defect

Convulsions/Epilepsy

Diabetes

Handicaps/Disabilities

Hearing Impairment

Heart Murmur

Hemophilia

Hepatitis

HIV+/AIDS

Kidney/Liver Problems

Psychological Counseling

Rheumatic/Scarlet Fever

Tuberculosis (TB)

Please discuss any medical problems that the patient has had

Does/Has the patient have/had any of the following habits?

Check the box, if yes.

Chew/Smoke Tobacco

Clenching/Grinding Teeth

Lip Sucking/Biting

Mouth Breather

Nail Biting

Nursing Bottle Habits

Speech Problems

Thumb/Finger Sucking

Tongue Thrust

Signature

Name

COVID-19 UPDATE

We at Rittenhouse Orthodontics have always followed the Infectious Diseases Control Policy to the highest level. In light of the recent COVID 19 pandemic, we have increased safety and sanitary measures to the highest level. Nowhere in Philadelphia will you find a safer location for Orthodontics. We are a virus-free practice. Click here to request an appointment.

REQUEST APPOINTMENT