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:
Whom may we thank for referring you to our practice?
Please list the names of any friends or family currently in the practice:
While every effort will be made to accommodate your schedule, some appointments require more time and will be scheduled during work and school hours.

Financial Party Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Email:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Work Phone #:
Who does the patient reside with?
If Other:

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Birthdate:
Policy Holder SSN:
Policy Holder's Employer:
Policy Holder's Address (if different from financial party):
City:
State:
Zip:
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 SSN:
Policy Holder's Employer:
Policy Holder's Address (if different from financial party):
City:
State:
Zip:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Have you used these benefits previously?

Emergency Contact Information

Name:
Address:
Relationship to Patient:
Phone:

Dental History

Dentist Name:
When was the last time the patient had a cleaning at their dentist?
What is the patients main orthodontic concern?
Please select Yes or No for the Following Questions - Do Not Leave Blank
Grind or clench teeth?
Injury to face, jaw, teeth or mouth?
Has the patient ever lost or chipped any teeth?
Oral habits (thumb/finger sucking)?
Snores during sleep?
Does the patient require antibiotic prophylaxis prior to dental procedures?
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:
City:
State:
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 Allergy
Metal Allergy/Nickel Sensitivity
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**

In the absence of written notice to the contrary, Omaha Orthodontics shall presume that any parent or legal guardian who presents a minor patient for treatment is the custodial parent or otherwise authorized legal guardian. Omaha Orthodontics is authorized to discuss the minor patient’s treatment, including progress and related clinical information, with such individual at the time of the appointment.

If a minor patient is accompanied by an adult other than a parent or legal guardian, Omaha Orthodontics shall reasonably rely on the representation that the custodial parent or legal guardian has authorized such individual to accompany the minor and to receive information regarding the minor’s treatment and progress during the appointment.

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.
Notice of Privacy Practices and Parental/Guardian Representation and Authorization

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.

Signature:
Date:

Patient Communication Opt-In Form

Text Messaging Opt-In:

Please check the box below to give your consent and opt in to receive text messages from our orthodontic office. By opting in, you agree to receive appointment reminders, important updates, and exclusive offers via text message. Standard messaging rates may apply.

*Please note that messaging is not a secure form of communication, and we recommend discussing any sensitive or personal information during your office visits. Thank you for choosing Omaha Orthodontics.

By signing below, I acknowledge that the information provided is accurate and complete to the best of my knowledge.

Signature:
Date: