Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Social Security #:
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?

Financial Party Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Email:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Social Security Number:
Do you have insurance that covers orthodontics?
If so, please name the Insurance Company:
Employer:
Occupation:
Length of Employment:
Work Phone:

Insurance Information

Insurance typically is paid over the course of treatment. For example, if treatment is estimated to be 2 years, the payments will come periodically over the course of treatment. Change in your insurance policy, for any reason, will affect the amount of the insurance to be received; therefore any changes must be reported to us as soon as possible. Any conflicts that arise with your insurance policy regarding payment of benefits will become your responsibility.

In cases where there is more than one insurance company involved, payments from the secondary company are, in most cases, dependent on what the primary insurance will pay. Please consult your insurance company manual to confirm their policy.

Signature
AUTHORIZATION TO RELEASE INFORMATION - I hereby authorize any Dentist, Physician, Hospital, Pharmacy, Insurance Company, Employer or Organization to release any information regarding the medical or dental history, treatment or benefits payable for this claim to The Plan Administrator or its authorized agent for the purpose of validating and determining benefits payable in connection with this claim. Data may be extracted for statistical, audit and verification purposes. I understand that I may request to receive a copy of this authorization:
Signature:
Date:
AUTHORIZATION TO PAY BENEFITS TO DENTIST – I hereby authorize payment directly to the above named Dentist of the Dental Benefits otherwise payable to me.
Signature:
Date:
CERTIFICATION – I certify that the foregoing information is true and correct.
Signature:
Date:

Dental History

Dentist Name:
Checkup Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when?
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.
Apprehensive about dental care?
Brush teeth daily?
Clench or grind teeth?
Discomfort from teeth or gums?
Floss teeth daily?
Fluoride treatments?
Frequently chew gum?
Frequent headaches?
Frequent sore throats?
Injury to face, jaw, teeth, or mouth?
Missing or extra permanent teeth?
Mouth breathing?
Neck or shoulder pain?
Oral habits (thumb or finger sucking, lip or nail biting)?
Pain, tenderness, or noise in either jaw?
Requires premedication?
Snores during sleep?
Speech problems or therapy?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of Last Physical:
Patient Health:
Address:
City:
State:
Zip:
Please list any medications currently being taken by the patient (include non-prescription):
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.
Anemia or blood disorder?
Arthritis or joint problems?
Asthma?
Bisphosphonates (Fosamax, Boniva)?
Bone disorders or loss?
Cancer?
Cancer in family history?
Diabetes?
Emotional problems treatment?
Endocrine problems?
Growth problems?
Handicaps or disabilities?
Heart attack or stroke?
Heart defect (congenital)?
Heart disease?
Heart murmur?
Hemophilia?
Hepatitis?
High blood pressure or hypertension?
HIV or AIDS?
Hormone therapy?
Ever been hospitalized?
Kidney disease?
Latex or Metal Allergy?
Liver disease, jaundice, or hepatitis?
Nervous disorders?
Pneumonia?
Prolonged bleeding or transfusion?
Radiation treatment?
Rheumatic fever?
Seizures, epilepsy, or neurological disease?
Tonsils or adenoids removed?
Tuberculosis or lung disease?
If any of the above medical questions were answered 'Yes' , please explain:

Patients Under 18

If 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?
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?
Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment:

Acknowledgement of Notice of Privacy Practices (HIPAA)

I hereby acknowledge that the Dixon Orthodontics HIPPA policy is posted in the reception area for review and that I may request a copy at any time. I understand that if I have any questions or complaints regarding my privacy rights that I may contact the office staff.
Signed:
Date:
If not signed by the patient, please indicate your relationship to the patient: