New Patient Form

"*" indicates required fields

Step 1 of 6

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Patient Biological Information

First Name*

Middle Initial

Last Name*

Nickname

Gender*

Birthdate*

Month

Day

Year

Address

Street Address City State ZIP Code

Primary Phone*

Alternate Phone

Please list the names of friends or family currently in the practice

Whom may we thank for referring you to our practice?

List any sports, hobbies, or musical instruments played

Financial Party Information

Check if the patient is also the person who will be financially responsible for treatment

Check if the patient is also the person who will be financially responsible for treatment

First Name*

Middle Initial

Last Name*

Birthdate*

Month

Day

Year

Relationship to Patient

Address*

Street Address City State ZIP Code

Primary Phone*

Alternate Phone

Insurance Information

Do you have insurance that covers orthodontics?

Yes

If so, please name the Insurance Company

Address

Street Address City State ZIP Code

Phone Number

Date of Birth of Insured

Group Number

Member ID

Employer

Occupation

Work Phone

Dental History

Dentist Name

Last Dental Visit

Has the patient had an orthodontic consult or treatment?

Yes

If so, when?

What is the patients main orthodontic concern?

Please select YES if the patient has had any of the conditions listed below either now or in the past..

Speech problems/therapy?*

Yes

Grind or clench teeth?*

Yes

Injury to face, jaw, teeth or mouth?*

Yes

Discomfort from teeth or gums?*

Yes

Pain, tenderness or noise in either jaw?*

Yes

Frequent headaches?*

Yes

Oral habits (thumb/finger sucking, lip/nail biting)?*

Yes

Neck/shoulder pain?*

Yes

Frequent sore throats?*

Yes

Brush teeth daily?*

Yes

Floss teeth daily?*

Yes

Fluoride treatments?*

Yes

Mouth breathing?*

Yes

Snores during sleep?*

Yes

Requires premedication?*

Yes

Any missing or extra permanent teeth?*

Yes

Apprehensive about dental care?*

Yes

Frequently Chew Gum?*

Yes

Any other dental concern we need to be aware of?

Medical History

Physician Name

Date of Last Physical

Month

Day

Year

Patient Health

Address

Street Address City State ZIP Code

List any medications currently being taken by the patient

List any drug allergies or sensitivities that the patient may have

Please select YES if the patient has had any of the conditions listed below either now or in the past..

Rheumatic Fever*

Yes

Tuberculosis/Lung Disease*

Yes

Pneumonia*

Yes

Liver Disease*

Yes

Kidney Disease*

Yes

Heart Attack/Stroke*

Yes

Heart Disease*

Yes

Congenital Heart Defect*

Yes

Heart Murmur*

Yes

Hemophilia*

Yes

Hypertension/High Blood Pressure*

Yes

Prolonged Bleeding/Transfusion*

Yes

Anemia*

Yes

HIV/AIDS*

Yes

Hepatitis*

Yes

Tonsils/Adenoids Removed*

Yes

Cancer*

Yes

Family History of Cancer*

Yes

Received Radiation Treatment*

Yes

Growth Problems*

Yes

Endocrine Problems*

Yes

Hormone Therapy*

Yes

Latex/Metal Allergy*

Yes

Nervous Disorders*

Yes

Bone Disorders/Bone Loss*

Yes

Diabetes*

Yes

Seizures/Epilepsy*

Yes

Handicaps/Disabilities*

Yes

Asthma*

Yes

Arthritis*

Yes

Treated for Emotional Problems*

Yes

Ever Been Hospitalized*

Yes

Take Bisphosphonates (Fosamax, Boniva)*

Yes

If any of the above medical questions were answered 'Yes' , please explain

Patients Under 18

If the patient is under the age of 18, please answer the following questions:

Please list the name and birthdate of any siblings

Height

Weight

School

Grade

Father/Guardian 1 Name

Mother/Guardian 2 Name

Has patient begun puberty?

Yes

If patient is a girl, has menstruation begun?

Yes

If patient is a boy, has their voice changed or have facial hair?

Yes

Has the patient grown in the past year or has their shoe size changed recently?

Yes

Has either biolog ical parent ever had orthodontic treatment?

Yes

Consent*

I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.*

Signature*

Date*

Month

Day

Year

Privacy Notice

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your protected health information (i.e., individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:

• To other health care providers (i.e., your general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you (i.e., to determine the results of cleanings, surgery, etc.);
• To third party payers or spouses (i.e., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e., to determine benefits, dates of payment, etc.);
• To certifying, licensing and accrediting bodies (i.e., the American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation;
• Internally, to all staff members who have any role in your treatment;
• To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling, etc.;
• To your family and close friends involved in your treatment; and/or,
• We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke.

Under the new privacy rules, you have the right to:

• Request restrictions on the use and disclosure of your protected health information; • Request confidential communication of your protected health information; • Inspect and obtain copies of your protected health information through asking us; • Amend or modify your protected health information in certain circumstances; • Receive an accounting of certain disclosures made by us of your protected health information; and, • .You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our Privacy Contact Person at our office address) or the United States Secretary of Health and Human Services (which must be filed within 180 days of the violation).

We have the following duties under the privacy rules:

• By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information;
• To abide by-the terms of our Privacy Notice that is currently in effect;
• To advise you of our right to change the terms of this Privacy Notice and to make the new notice provisions effective for all protected health information maintained by us, and that if we do so, we will provide you with a copy of the revised Privacy Notice.

Please note that we are not obligated to:

• Amend your protected health information if, for example, it is accurate and complete;
or,
• Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.

This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Contact Person or direct your questions to this person at our office address. Thank you.

PATIENT ACKNOWLEDGMENT

I hereby acknowledge that I have received and reviewed a copy of this Privacy Notice.

Patient / Parent / Guardian Signature*

Date*

Month

Day

Year

Authorization for Release of Protected Health Information

Patient's Name*

Date of Birth*

Month

Day

Year

Authorization for release of Protected Health Information to family members, significant others, and/or friends.

I authorize release of any and all health information including diagnosis. dental records. digital x-rays. rendered and the release of financial and/or insurance claim Information.

This information may be released to:

Name

Relationship

Name

Relationship

Name

Relationship

Name

Relationship

information may ONLY BE RELEASED TO ME

information may ONLY BE RELEASED TO ME

This authorization for release of information will remain in effect for the duration of your active orthodontic treatment.

Patient/Parent/Guardian Signature*

Date*

Month

Day

Year

Relationship to patient (if minor)

Patient Biological Information

Financial Party Information

Insurance Information

Dental History

Medical History

Patients Under 18

Privacy Notice

Authorization for Release of Protected Health Information

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