Date: Patient’s name:
Address: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--District of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands
Home Phone: Contact e-mail address: Birthdate: Social Security: #
If patient is a minor, give parent’s or guardian’s name: Whom may we thank for referring you to our office?
Name:
Residence: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--District of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands
Mailing Address: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--District of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands
Home phone: Work phone: Social Security: # Birthdate: Relationship to Patient: Employer: Occupation:
Do You Have Insurance?YesNo
Insured’s Name: Insured’s Social Security: # Insurance Company: Group No. : ID : # Insurance Co. Address: Phone No.:
Emergency Information Name of nearest relative not living with you: Complete address: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--District of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands
Phone:
Physician: Date of Last Visit: Address: Phone: Are you taking any medication? (If Yes, please fill in details) YesNo Details: Are you allergic to any medication? (If Yes, please fill in details) YesNo Details: Do you have a history of a major illness? (If Yes, please fill in details) YesNo Details: Have you had any major operations? (If Yes, please fill in details) YesNo Details: Have you ever been involved in a serious accident? (If Yes, please fill in details) YesNo Details:
Check any of the medical conditions below that you have had or currently have. Abnormal bleeding/HemophiliaDiabetesHepatitis/Liver problemsPneumoniaAnemiaDizzinessHerpesProlongedBleedingArthritisEpilepsyHigh Blood PressureRadiation/ChemotherapyAsthma or HayfeverGastrointestinal DisordersHIV / AidRheumatic FeverBone DisordersHeart ProblemsKidney problemsTuberculosisCongenital Heart DefectHeart MurmurNervous DisordersTumor or Cancer
Are there any medical conditions we have not discussed that you feel we should be aware of?
Check any of the allergies below that you have had or currently have. LatexPenicillinCodeineErythromycinTetracyclineAspirinIbuprofenMetalsOther
Check any below that you have had or currently have. RheumFeverProsthesisConvulsions/epilepsyHearing impairmentHandicaps/disabilitiesHistory of Scarlet Fever
Check any of the child habits your child have. Thumb sucking/Finger suckinglip Sucking/bitingNail bitingNursing Bottle HabitsTrouble chewing
Dentist: Date of last visit: What concerns you most about your teeth? Are you presently in any dental pain? YesNo Have you ever experienced any unfavorable reaction to dentistry? YesNo Have you ever lost or chipped any teeth? YesNo Have there been any injuries to face, mouth or teeth? YesNo Is any part of your mouth sensitive to temperature or pressure? YesNo Do your gums bleed when you brush? YesNo Do you have any type of thumb or tongue habit? YesNo Are you a mouth breather? YesNo Have you ever seen an orthodontist? YesNo If yes, who and when? Would you object to wearing orthodontic appliances (braces) should they be indicated? YesNo Has anyone in your family received orthodontic treat ment? YesNo How did they feel about the result? What is your attitude toward receiving orthodontic treatment? Do your teeth or jaws ever feel uncomfortable when you awake in the morning? YesNo Are you aware of your jaw clicking or popping? YesNo Are you aware of clenching your teeth during the day? YesNo Have you ever been told that you grind your teeth? YesNo Do you have “tension” headaches? YesNo Have you ever experienced chronic ringing in your ears? YesNo Height of parents? Mom Dad Has menstruation started? YesNo Are you aware that some appointments will be during school/work hours? YesNo Please list some hobbies or interests:
Are you pregnant? YesNo
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.
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: Email: Name: Email: Name: Email: Name: Email:
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.
Signature:
Benefits of Orthodontics: Aesthetics, Health and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph, I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. to perform a complete orthodontic evaluation. Date: Signature:
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