Confidential Patient Information

* First Name:
MI:
* Last Name:
* I prefer to be called:
* Birthdate:
* Assigned Gender at Birth:
* Address:
* City:
* State:
* Zip:
* Main Phone:
Second Phone:
* Email:
Have any other family members been treated in this office? Please name them.
* Whom may we thank for referring you to our office?
If patient is a minor:
Who will be responsible for bringing the patient to orthodontic appointments?
Patient lives with:
Relationship To Patient:
Custodial Parent(s) Name:

Financial Party Information

* First Name:
Middle Initial:
* Last Name:
Marital Status:
Relationship to Patient:
* Birthdate:
* Address:
* City:
* State:
* Zip:
* Main Phone:
Second Phone:
Email:
Social Security #:
Employer:
Occupation:
Work Phone #:
Responsible Party 2
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Marital Status:
Relationship to Patient:
Birthdate:
Main Phone:
Second Phone:
Email:
Social Security #:
Employer:
Occupation:
Work Phone #:

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Policy Holder's Date of Birth:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Do you have dual dental coverage?
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Policy Holder's Date of Birth:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:

Tell Us About You

How do you feel about orthodontic treatment (i.e. nervous, excited, a bit of both)?
What activities do you love to do (like sports, music, or hobbies)?
Do you have any special events coming up that you’d like us to know about (wedding, celebrations, etc.)? If yes, please explain
Is there anything that helps you feel more comfortable during visits (like headphones, a blanket, or holding something in your hands)? If yes, please explain
Are there any social or self-esteem concerns involving the teeth or smile that make you interested in starting orthodontic treatment? If yes, please explain

Dental History

Dentist Name:
Check-up Frequency:
Last Dental Visit:
* What are your main concerns/goals that you would like orthodontics to accomplish?
Describe any previous orthodontic treatment or consultations
Other dental specialists now being seen:
Name:
Reason:
* Do you have any of the following dental conditions? If so, please mark them.
Other
If you have/had any of the above, please explain:
* Do you have any dental work that needs to be completed?
Other
If you have/had any of the above, please explain
* Do you have any oral or myofunctional habits?
Other:
If you have/had any of the above, please explain
* Do you have any jaw or TMJ problems?
Other:
If you have/had any of the above, please explain

Medical History

* Have you been told by your physician to take antibiotic pre-medication before dental treatments?
* List any prescription medication currently being taken (or type none):
* Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
* Do you have any of the following allergies?
Other:
If you have/had any of the above, please explain
List any drug allergies or sensitivities (not listed above) that the patient may have:
* Have you ever been diagnosed with or treated for any of the following mental health conditions?
Other:
If you have/had any of the above, please explain:
* Do you have any of the following blood disorders?
Other:
If you have/had any of the above, please explain:
* Do you have any of the following types of cancer?
Other:
If you have/had any of the above, please explain:
* Do you have any of the following cardiovascular or circulatory conditions?
Other:
If you have/had any of the above, please explain :
* Do you have any of the following ENT or sleep conditions?
Other:
If you have/had any of the above, please explain:
* Do you have any of the following endocrine or metabolic conditions?
Other:
If you have/had any of the above, please explain:
* Do you have any of the following gastrointestinal, liver, or kidney conditions?
Other:
If you have/had any of the above, please explain:
* Do you have any of the following infectious or viral conditions?
Other:
If you have/had any of the above, please explain:
* Do you have any of the following lifestyle habits?
Other:
If you have/had any of the above, please explain::
* Do you have any of the following musculoskeletal, bone, or genetic disorders?
Other:
For those that have a current or history of bisphosphonate use – please provide details of treatment received including dates and whether oral or injection:
If you have/had any of the above, please explain:
* Do you have any of the following neurological conditions?
Other:
If you have/had any of the above, please explain:
* Do you have any of the following respiratory conditions?
Other:
If you have/had any of the above, please explain:
* Do you have any of the following general heath or surgical history?
Other medical conditions not mentioned above (please explain):
If you have/had any of the above, please explain:
For Patients Assigned Female at Birth
Are you pregnant?

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 use of your privacy right 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, and,
  • 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 make available to you, a copy of the revised Privacy Notice.

Please note that we are not obligated to:

  • Honor any request by you to restrict the use or disclosure of your protected health information;
  • 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 accidentally 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.