Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Social Security #:
If patient is a minor, who is the parent or guardian?
If patient is a minor, who does the patient live with?
What are the names of any friends or family currently in the practice?
What are the patient's interests (i.e. sports, hobbies, or musical instruments)?

Financial Party Information

First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Birthdate:
Address:
City:
State:
Zip:
How long at this address?
Previous address (less than 3 years)?
Email:
Main Phone:
Cell Phone:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Work Phone:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Birthdate:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Work Phone:

Dental Insurance Information

Policy Holder's Name:
Policy Holder's Date of Birth:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Do you have dual dental coverage?
(If yes, complete information below)
Policy Holder's Name:
Policy Holder's Date of Birth:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:

Emergency Contact Information

Name:
Address:
Relationship to Patient:
Phone:

Dental History

Dentist Name:
Checkup Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when?
Does the Patient need to premedicate prior to dental visit?
What is the patient's main orthodontic concern?
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Abnormal swallowing (tongue thrust)?
Apprehensive about dental care?
Bad taste or mouth odor?
Bleeding gums?
Chipped or injured permanent teeth?
Clench or grind teeth?
Discomfort from teeth or gums?
Fluoride treatments?
Frequent canker sores or cold sores?
Frequent headaches?
Have wisdom teeth been removed?
Injury to face, jaw, teeth, or mouth?
Jaw fractures, cysts, or mouth infections?
Missing or extra permanent teeth?
Mouth breathing?
Oral habits (thumb or finger sucking, lip or nail biting)?
Other periodontal (gum) problems?
Pain, tenderness, or noise in either jaw?
Problems with food trapped between teeth?
Snores during sleep?
Speech problems or therapy?
Teeth sensitive to hot or cold?
Teeth that irritate tongue, cheek, lip, etc?
Thumb or finger habit as a child?
Is all dental work completed at this time?
If any of the above dental questions were answered 'Yes', please explain:
Please select 'Yes' if the patient has had any of the TMJ conditions listed below either now or in the past. Cannot be blank.
Do you have a history of jaw joint problems?
Have you been treated for "TMJ"?
Do you notice clicking or popping in your jaw joint?
Has your jaw ever locked?
Do you have difficulty chewing or opening your mouth?
Does your bite feel uncomfortable or unusual?
Do you experience soreness in the muscles of your face or around your ears?
If any of the above TMJ questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of Last Physical:
Patient Health:
Address:
City:
State:
Zip:
Has there been any change in the patient's general health within the last year?
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
Has the patient had a serious illness or hospitalization in the past 5 years? If so, what for?
Please list any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Aspirin, Ibuprofen, or Tylenol?
Codeine or other narcotics?
Latex?
Local anesthetics?
Metal?
Penicillin or other antibiotics?
Sulfa drugs?
Other?
Please list any other 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. Cannot be blank.
Angina?
Anemia or blood disorder?
Arteriosclerosis?
Arthritis or joint problems?
Asthma?
Bed wetting?
Bisphosphonates (Fosamax, Boniva)?
Bone disorders or loss?
Bone fractures or trauma to face or jaw?
Cancer?
Cancer in family history?
Chronic fatigue?
Diabetes?
Emotional problems treatment?
Growth problems?
Handicaps or disabilities?
Heart attack or stroke?
Heart defect (congenital)?
Heart disease?
Heart murmur?
Heart valves are damaged or artificial?
Hemophilia?
High blood pressure or hypertension?
HIV or AIDS?
Hormone therapy?
Kidney disease?
Liver disease, jaundice, or hepatitis?
Low blood pressure?
Nervous disorders?
Persistent cough?
Persistent swollen neck glands?
Pneumonia?
Prolonged bleeding or transfusion?
Prosthetic joints?
Radiation treatment?
Respiratory problems or emphysema
Rheumatic fever?
Seizures, epilepsy, or neurological disease?
Sexually transmitted disease?
Sinus trouble?
Stomach ulcer or hyperacidity?
Substance abuse problem (past or present)?
Thyroid or endocrine problems?
Tonsils enlarged?
Tonsils or adenoids removed?
Tuberculosis or lung disease?
FEMALES: Are You Pregnant?
If any of the above medical questions were answered 'Yes' , please explain:

Patient Motivation For Orthodontic Treatment

How would you change your teeth?
How would you change your facial appearance?
Where would you like to reduce the pain or discomfort?

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Height:
Weight:
School:
Grade:
Has patient begun puberty?
If patient is a girl, has menstruation begun?
If patient is a boy, has their voice changed or have facial hair?
Has the patient grown in the past year or has their shoe size changed recently?
Has either biological parent ever had orthodontic treatment?

Notice of Privacy Practices

This notice describes how your health information may be used and disclosed and how you can access this information. Please review it carefully. Protecting our patients’ privacy has always been important to this practice. The Health Insurance Portability and Accountability Act (HIPPA) requires us to inform you of certain policies.

At Stephen S. Yang, DMD, MS, Inc., we have always kept your health information secure and confidential. This law requires us to continue maintaining your privacy, to give you this notice, and to follow the terms of this notice.

The law permits us to use or disclose your health information for payment of your services. For example, we may send a report of your progress to your insurance company.

We may use or disclose your health information for our normal healthcare operations. For example, one of our staff will enter your information into our computer.

We may share your information with our business associates, such as a billing service. We have a written contract with each business associate that requires them to protect your privacy.

We may use your information to contact you. For example, we may send newsletters or other information. We may also want to call and remind you about your appointments. If you are not at home, we may leave this information on your answering machine or with the person who answers the telephone.

Unless you notify us in writing otherwise, we may use your photos, x-rays, and study models for educational, social media, and/or marketing purposes and for display inside the office.

In an emergency, we may disclose your health information to a family member or another person responsible for your care.

We may release some or all of your health information when required by law.

If this practice is sold, your information will become the property of the new owner.

Except as described above, this practice will not use or disclose your health information without your prior written authorization. You may request in writing that we not use or disclose your health information as described above. We will let you know if we can fulfill your request.

You have the right to know of any uses or disclosures we make with your health information beyond the above normal uses.

As we will need to contact you from time to time, we will use whatever address or telephone number you prefer.

You have the right to transfer copies of your health information to another practice. Give us a written request indicating the copies you want transferred and we will mail (or e-mail) your files for you. We may charge you a reasonable fee for this service.

You have the right to see or receive a copy of any of your health information, with a few exceptions. Give us a written request regarding the information you want to see or have copied. We may charge a reasonable fee for the copies.

You have the right to request an amendment or change to your health information. Give us your request to make changes in writing. If you wish to include a statement in your file, please give it to us in writing. We may or may not make the changes you request, but will be happy to include your statement in your file. If we agree to an amendment or change, we will not remove or alter earlier documents, but will add new information.

You have the right to receive a copy of this notice.

If we change any of the details of this notice, we will notify you of the changes in writing.

You may file a complaint with the Department of Health and Human Services, 200 Independence Ave, S.W., Room 509E, Washington, D.C. 20201. You will not be retaliated against for filing a complaint.

However, before filing a complaint, or for more information or assistance regarding your health information privacy, please contact our Privacy Office, Mirian Osorio at (650) 366-2520.

Acknowledgment
I have received a copy of the Stephen S. Yang, DMD, MS, Inc Notice of Privacy Practices.
Print Name:
Signature:
Date:
If signing as a parent or guardian, please print the name of the patient

How Did You Hear About Us?

Knowing where our patients are hearing about us allows us to optimize our marketing efforts and keep costs down. Please take a moment to let us know the main way you heard about our office. If you heard about us from multiple sources, please select "Other" and include details in the box below.














Please list all of your friends that referred you here, so we may thank them properly.
By typing in my name below, I understand that the information I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidence, and it is my responsibility to inform this office of any changes in my medical, dental, or insurance status. I understand that I am responsible for payment of services rendered and also responsible for paying any copayment and deductibles that my insurance does not cover. I hereby authorize the release of any information related to insurance claims. I consent to the examination by the doctor and I authorize payment of any insurance benefits to the office. I understand that where appropriate, credit bureau reports may be obtained for the purpose of considering payment options.
Responsible Party Signature:
Date: