Confidential Patient Information

Patient First Name:
Middle Initial:
Patient Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Social Security #:
School:
Grade:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Please list the names of any friends or family currently in the practice:

Financial Party Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Email:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Social Security #:
Employer:
Occupation:
Work Phone #:
Will there be more than one party financially responsible? If yes, then please fill out the information below.
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Birthdate:
Social Security Number:
Email:
Phone:
Address:
City::
State:
Zip:
Employer:
Occupation:
Work Phone:
Do you have insurance that covers orthodontics?
Which parent does the patient reside with?
If Other:

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Birthdate:
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:
Relationship to Patient:
Policy Holder's Birthdate:
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:
Check-up Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
If so, when?
What is the patients main orthodontic concern?
Are you aware that some appointments will be during school/work hours?
When was the last time the patient had a cleaning at their dentist?
Please select Yes or No for the Following Questions - Do Not Leave Blank
Speech problems/therapy?
Grind or clench teeth?
Injury to face, jaw, teeth or mouth?
Ever experienced any unfavorable reaction to dentistry?
Has the patient ever lost or chipped any teeth?
Oral habits (thumb/finger sucking, lip/nail biting)?
Mouth breathing?
Snores during sleep?
Requires premedication?
Any missing or extra permanent teeth?
Apprehensive about dental care?
Is the patient sensitive or self-conscious about his/her teeth?
Does the patient’s mouth or either jaw have any sensitivity or discomfort?
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:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select Yes or No for the Following Questions - Do Not Leave Blank
Tuberculosis/Lung Disease
Hepatitis
Seizures/Epilepsy
Is the patient pregnant
HIV/AIDS
Herpes
Latex/Metal Allergy
Handicaps/Disabilities
If any of the above medical questions were answered ‘Yes’, or you have any additional medical concerns that you would like us to be aware of, please explain:

Acknowledgement of Receipt of Notice of Privacy Practices

**You may refuse to Sign This Acknowledgement**

Omaha Orthodontics will assume the parent that brings the patient to our office is the custodial parent and we will release information regarding treatment progress to that parent at the appointment.

If another relative/adult brings the child to the appointment, we will assume that the custodial parent has given permission for that person to receive updates on treatment progress while the child is in our office.

Please authorize the release of Parent information to the following people by phone or in the child’s absence.

I acknowledge that I have received a copy of Omaha Orthodontics Notice of Privacy Practices on behalf of myself or my dependent:

I understand this notice explains how my protected health information is used and disclosed by the practice, and my rights regarding my protected health information.

I understand I should keep the Notice and refer to it if I have questions. I also understand I should contact the Compliance at compliance@sdbmail.com if I have a question or concern about my privacy rights.

DISCLAIMER: By typing your name below, you are giving your electronic signature. You agree that your electronic signature is the legal equivalent of your manual signature.