Patient Information

We would like to welcome you to our office. Our goal is to help you achieve a beautiful smile and while reaching and maintaining maximum oral health in a warm, courteous, safe and caring environment. Please fill out this form completely.
Patient First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Age
School:
Grade:
Home Phone:
Cell Phone:
Home Address:
City:
State:
Zip:
Parent's Full Name:
Mother's Address (if different than above):
Cell Phone:
Cell Provider:
Email:
Home Phone:
Employer:
Work Phone:
Father's Address (if different than above):
Cell Phone:
Home Phone:
Father Employer:
Father Work Phone:
How may we best contact you to make appointments?
Person financially responsible for account
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Emergency Contact other than Parent(s) in case we are unable to reach a parent.
Name:
Relationship:
Phone:
Are there any siblings?
Name:
Sibling Age
Seen by us
Name:
Sibling Age
Seen by us
Name:
Sibling Age
Seen by us
Dentist Name:
Physician Name:
Whom may we thank for referring you to our practice?

Medical History

Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Abnormal Bleeding?
ADD, ADHD, PDD?
Allergies?
Allergies to drugs, substances?
Any Operations?
Artificial Joints (hip, etc)?
Asthma?
Austism, Asperger's Syndrome?
Cancer?
Cold Sores/Fever Blisters?
Diabetes?
Diet (special, restricted)?
Emphysema?
Fainting or Dizzy Spells?
Glaucoma?
Growth problems?
Handicaps or disabilities?
Hearing Impairment?
Heart attack or stroke?
Heart defect (congenital)?
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?
Low Blood Pressure?
Mitral Valve Prolapse?
Nervous disorders?
Osteoporosis/Osteopenia?
Pacemaker?
Precocious Puberty?
Prolonged bleeding or transfusion?
Psychiatric/Psychological Problems?
Radiation treatment?
Rheumatic fever?
Seizures, epilepsy, or neurological disease?
Severe or Frequent Headaches?
Sickle Cell Disease?
Sleep Apnea?
Thyroid Problems?
Tuberculosis or lung disease?
Tumors?
Ulcers/Stomach Disorders?
Venereal Disease?
If any of the above medical questions were answered 'Yes' , please explain:
Physical Development:
Percentile Height:
Percentile Weight:
Adenoids or tonsiles been removed?
Boys - Voice Change? If yes, when did it change?
Girls - Onset of Menstruation? If yes, date of onset?
Currently under the care of a physician? If yes, for what condition?
Have you been a hospital patient during the past two years?
Women
Are you pregnant? Week #:
Nursing?
Taking birth control pills?
Please list any medications currently being taken by the patient and the reason for medication (include non-prescription):
Have you ever been treated with medications for osteoporosis, osteopenia, abnormal bone conditions or cancer? If yes, please list name of medication(s): (i.e., Fosamax, Actonel, Zometa, Aredia, Boneva, etc.)
Please list any other drug allergies or sensitivities that the patient may have:

Dental History

Has the patient had an orthodontic consult or treatment?
Why did you come to the orthodontist today?
Last Dental Visit:
Full x-rays
Ever had serious/difficult problems associated with previous dental work?
Experienced early or late tooth eruption?
Play any musical wind instrument?
Ever had?
Oral Surgery
Serious Injury (mouth/head)
Periodontal Treatment
Ever experienced?
Difficulty in chewing
Tired jaws
Pain (joint, ear, face)
Problem opening, closing mouth
Headaches
Clicking or popping of jaw
Tongue Thrust
Lip Biting
Thumb/Finger Sucking
Nail/Pencil Biting
Tooth Grinding
Nursing Bottle Habits
Mouth Breather
Do you frequently get cold sores, blisters or any other oral lesions?
Your current dental health is:
Do your gums ever bleed?
Do you like your smile?

As a courtesy and service to our patients we will provide a "super bill" that you may submit with your claim form for reimbursement from your insurance company. We do not accept assignment of benefits from the insurance companies.

Is is important to attend appointments. Please understand that a last minute cancellation or "no show" does not allow us enough time to accommodate another patient. Because the time we allot is valuable, kindly give our office 24 hours notice if you must cancel an appointment.

I understand that I am responsible for all costs of orthodontic treatment and that in the event of a default of one of the responsible parties/parents, I am entirely responsible for all costs of orthodontic treatment and will pay them in a timely manner.

Sigature of Responsible Person(s):
Date:
Signature of Responsible Person(s):
Date:

Patient Consent for Use and Disclosure of Protected Health Information

I HEREBY GIVE MY CONSENT FOR DR. COTZAS OFFICE (REFERRED TO AS "OUR OFFICE") TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION (PHI) ABOUT ME TO CARRY OUT TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS (TPO). THE PRIVACY NOTICE PROVIDED BY DR. COTZAS OFFICE DESCRIBES SUCH USES AND DISCLOSURES MORE COMPLETELY.

I have the right to review the Privacy Notice prior to signing the consent. Our office reserves the right to revise the privacy notice at any time. A revised privacy notice may be obtained by forwarding a written request to our privacy officer.

With this consent, our office may call my home or other alternative locations and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out treatment, payment, and health care operations, such as appointment reminders, insurance items, and any calls pertaining to any clinical care, including laboratory test results, among others.

With this consent, our office may mail to my home other or other alternative locations any items that assist the practice in carrying out treatment, payment, and health care operations, such as appointment reminders cards and patient statements.

With this consent, our office may email to my home or other alternative location any items that assist the practice in carrying out treatment, payment, and health care operations, such as appointment reminders cards and patient statements. I have the right to request that our office restrict how it uses or discloses my PHI to carry out treatment, payment, and health care operations. This practice is not required to agree to any requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to allow our office to use and disclose my PHI as set forth in the Privacy Notice to carry out treatment, payment, and health care operations.

I may revoke my consent in writing except to the extent that the practice has already made disclosures reliant upon any prior consent. If I do not sign this consent, or later revoke it, our office may decline to provide treatment to me.

Signature of Patient or Legal Guardian:
Date:

Office Policies and Fees

Please read and sign this form. If you have any questions, please ask our front desk staff. Thank you.

  • Office hours are Monday through Thursday 8:00 am to 6:00 pm. Friday office hours are 9:00 am to 5:00 pm for patient emergencies and administrative purposes only.
  • If I need to cancel or reschedule an appointment, I understand that I must give the office at least 24-hour advance notice.
  • I understand that Dr. Cotzas does not accept insurance and I am fully responsible for the fees incurred. Payment is due at the time services are rendered and a “superbill” will be generated with all necessary information that the patient may submit to their insurance for reimbursement. If an installment plan is in place, I understand that I will be responsible for making the monthly payment by the 15th of every month otherwise I will be subject to a $15.00 late fee for each month the payment is delinquent.
  • I understand that Dr. Cotzas office requires all appointments to be confirmed one business day prior to the scheduled appointment. Confirmation texts and emails are sent out one or two business days prior to the appointment so please reply to them with a yes or no answer. If we do not receive a reply text or email confirmation for the appointment, a phone call will then be made to you for the confirmation. If we do not receive a response at least 24 hours before the appointment, we reserve the right to cancel the appointment and give it to another patient.
  • I understand that if a non-urgent message is left at the office after 6:00 pm Monday through Thursday, the call will be returned the next business day after 8:00 am. If a non-urgent message is left after 5:00 pm Friday, anytime Saturday, Sunday or on a holiday, the call will be returned the next business day after 8:00 am.
  • When Dr. Cotzas is out of the office, there is always a local orthodontist on call for emergencies. When calling our office, the answering machine will identify that orthodontist and their phone number. Kindly leave a message on our machine stating the emergency but also call the covering doctor who will be happy to take care of the emergency for you.
  • It is important that all patients bring any and all appliances (that are part of their treatment) with them including headgear and retainers. We will provide rubber bands, retainer cases and wax as needed.

By signing this form, I give the office of Dr. Mike Cotzas consent to call my home or cell phone and leave a message on voicemail or in person as well as send emails and/or text messages to the address I provide in reference to any items that assist the practice in carrying out treatment, payment, and healthcare operations, such as appointment reminders or any calls pertaining to my child’s or my clinical care. I have the right to request that the office restrict how it uses or discloses my PHI to carry out treatment, payment, or health care operations. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. I understand and agree to all the above.

Parent/Patient Signature:
Date: