About You

First Name:
Middle Initial:
Last Name:
Preferred Name:
Gender:
Address:
City:
State:
Zip:
Cell Phone:
Email:
Preferred appointment reminder method?
Marital Status:
Birthdate:
Social Security Number:
Employer:
Position/Occupation:

Emergency Contact Information

Name:
Relation:
Phone:

Spouse Information

Name:
Phone:

Dentist Information

Dentist Name:
Address:
Phone:
Date of last exam/cleaning:
Any outstanding dental work? If yes, please explain:
Were you referred to us? If yes, please explain:

Dental Insurance Information

Primary Insurance
Subscriber Employer:
Position:
Insurance Name:
Phone:
Subscriber's Name:
Subscriber's Birthdate:
Subscriber's ID:
Group ID:
Ortho coverage known?
If so, benefit amount:
Secondary Insurance, if any
Subscriber Employer:
Position:
Insurance Name:
Phone:
Subscriber's Name:
Subscriber's Birthdate:
Subscriber's ID:
Group ID:
Ortho coverage known?
If so, benefit amount:

Medical History

Patient's Physician:
Phone:
Last Exam:
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?
Asthma?
Birth Defect?
Bleeding Disorder?
Cancer?
Cleft Lip/Palate?
Cold Sores?
Cystic Fibrosis?
Developmental Disorder/Delay?
Diabetes?
Emotional problems treatment?
Endocrine or thyroid problems?
Eye Disorder?
Hearing Problems?
Heart disease?
Heart murmur?
Hepatitis?
HIV or AIDS?
Injury to Face/Teeth/Gums?
Kidney disease?
Liver disease, jaundice, or hepatitis?
Neurological Disorder?
Prolonged bleeding or transfusion?
Rheumatic fever?
Seizures, epilepsy, or neurological disease?
Speech Difficulty?
Tonsils or adenoids removed?
Tuberculosis or lung disease?
Advised to take antibiotics prior to dental visit?
If any of the above medical questions were answered 'Yes' , please explain:
List any conditions not mentioned:
Have you taken any oral or IV bisphosphonate drugs (Boniva, Fosamax, etc):
Please list any medications currently being taken by you (include non-prescription):
Please list any drug allergies or sensitivities that you may have (medications, latex, etc):

Dental and Orthodontic History

Chief Complaint/Concern:
Previous Orthodontic Treatment:
If yes, please explain:
Any missing teeth:
If yes, please explain:
Any jaw joint pain/discomfort:
If yes, please explain:
Any history of dental trauma:
If yes, please explain:
Do you grind your teeth at night:
If yes, do you wear a bite splint:
How often do you brush:
How often do you floss:
Patient Signature:
Date:

HIPAA Consent

This consent form allows Great Lakes Orthodontics to use and disclose information about me protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This information may be used or disclosed to carry out treatment, payment, or health care operations. I acknowledge that Great Lakes Orthodontics (GLO) has provided me with a Notice of Privacy Practices, which more completely describes such uses and disclosures. I understand that I have the right to review and I have reviewed the Notice of Privacy Practices prior to signing this document. I understand that the terms of this document may change and that I may obtain revised notices by contacting the Privacy Officer.

I UNDERSTAND:

  • My PHI means health information, including my demographic information, collected from me and created or received by my doctor, another health care provider, a health plan, or a healthcare clearinghouse. This Protected Health Information (PHI) relates to my physical or mental health and identifies me or provides reasonable basis to believe the information may identify me.
  • I understand that I have the right to request how protected health information is used or disclosed to carry out treatment, payment, and health care operations and must be provided to me in writing.
  • I understand that I may request restrictions of my PHI, but Great Lakes Orthodontics is not required to agree to these restrictions if they interfere with reasonable delivery of care. However, if Great Lakes Orthodontics agrees to a restriction that I may request, the restriction is binding on Great Lakes Orthodontics.
  • I understand that I have the right, at any time, to revoke this consent, provided that I do so in writing, but Great Lakes Orthodontics may still use information to complete any actions that it began prior to my revoking consent and which rely on my PHI. I understand that Great Lakes Orthodontics may refuse service if I revoke this consent.

I AUTHORIZE:

  • Great Lakes Orthodontics to leave messages on my voicemail to confirm appointments, and/or may speak with other members of my household and leave messages with them regarding my upcoming appointments.
  • Great Lakes Orthodontics to disclose my health information to any person(s) who may accompany me to my appointment and are present with me during my visit with the orthodontist and staff.
  • Great Lakes Orthodontics to communicate with me using unsecured email and mobile messaging to transmit information related to scheduling of appointments and information related to billing and payment.
  • Great Lakes Orthodontics to communicate or consult with other health professionals or staff who may be involved in the delivery of my health or dental care.
  • Great Lakes Orthodontics to disclose my PHI to my emergency contact and the following persons:
Name:
Relationship To Patient:
Phone:
Name:
Relationship To Patient:
Phone:
By my signature below, I affirm the above information:
Signature of Patient:
Date: