Confidential Patient Information
Patient's First Name:
Patient's Middle Initial:
Patient's Last Name:
Nickname/Preferred Name:
Birthdate:
Gender:
Male
Female
Non-binary
Please list the names and ages of all children in the family (if applicable):
Whom may we thank for referring you to our practice?
What is the patient's main orthodontic concern?
Responsible Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Self
Mother
Father
Guardian
Grandparent
Stepmother
Stepfather
Spouse
Other
Email:
Address:
City:
State:
Zip:
Cell Phone:
Secondary Phone:
Marital Status
Single
Married
Divorced
Remarried
Widowed
Other
Do you have insurance that covers orthodontics?
No
Yes
If so, please name the Insurance Company:
Member ID Number:
Group ID Number:
Primary Insurance Subscriber's Name:
Primary Insurance Subscriber’s Date of Birth:
Provider Service Phone Number and Address (usually on the back of the card):
Do you have a secondary insurance that covers orthodontics?
No
Yes
If so, please name the Insurance Company:
Member ID Number:
Group ID Number:
Provider Service Phone Number and Address (usually on the back of the card):
Secondary Insurance Subscriber's Name:
Secondary Insurance Subscriber’s Date of Birth:
Responsible Party 2
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Self
Mother
Father
Guardian
Grandparent
Stepmother
Stepfather
Spouse
Other
Email:
Address:
City:
State:
Zip:
Cell Phone:
Secondary Phone:
Marital Status
Single
Married
Divorced
Remarried
Widowed
Other
Is there a dental insurance policy under this responsible party's name?
No
Yes
If so, please name the insurance company:
Member ID Number:
Group ID Number:
Provider Service Phone Number and Address (usually on the back of the card):
Responsible Party 3
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Self
Mother
Father
Guardian
Grandparent
Stepmother
Stepfather
Spouse
Other
Email:
Address:
City:
State:
Zip:
Cell Phone:
Secondary Phone:
Marital Status
Single
Married
Divorced
Remarried
Widowed
Other
Is there a dental insurance policy under this responsible party's name?
No
Yes
If so, please name the insurance company:
Member ID Number:
Group ID Number:
Provider Service Phone Number and Address (usually on the back of the card):
Additional Emergency Contact (other than Responsible Party/Self)
Name:
Relationship to patient:
Cell Phone:
Dental History
Dentist Name:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, please describe and provide dates.
No
Yes
Has the patient been treated by another dental specialist (periodontist, endodontist, oral surgeon, etc)? If so, please describe and provide details:
No
Yes
Please respond to the following by selecting YES or NO (if YES, please fill in details). Parents/guardians please respond for minors.
Injuries to face, jaw, mouth, or teeth?
No
Yes
Missing or extra permanent teeth?
No
Yes
Thumb or tongue habit?
No
Yes
Jaw joint problems?
No
Yes
Habits such as grinding or clenching?
No
Yes
Been teased about the appearance of your teeth?
No
Yes
Medical History
Please respond to the following by selecting YES or NO (if YES, please fill in details). Parents/guardians please respond for minors.
Are you taking any medications/supplements? If yes, please list.
No
Yes
Are you taking or have you ever taken bisphosphonates for osteoporosis or other bone diseases?
No
Yes
Are you allergic to any medications, latex, metals, or foods?
No
Yes
Do you have a history of a major illness, operation, or accident?
No
Yes
Does your physician recommend premedicating with antibiotics prior to dental procedures?
No
Yes
Do you smoke or use tobacco in any form?
No
Yes
If you have any medical conditions, including any in the following list, please list/elaborate in the box below:
Abnormal bleeding/hemophilia, ADHD, anemia, anxiety/depression, arthritis, artificial joints/valves, asthma, autism/Asperger’s syndrome, bone disorders, cancer, congenital heart defects, diabetes, eating disorders, epilepsy, gastrointestinal disorders, growth disorders, heart problems or heart murmur, hepatitis or liver problems, high blood pressure, HIV/AIDS, kidney problems, psychiatric care, radiation treatment, sleep apnea, speech disorders/problems, stroke
Female patients only:
Are you pregnant?
No
Yes
*
I have read and understand the above questions. I will not hold my orthodontist or any member of the practice responsible for any errors or omissions that I have made in the completion of this form. If there are any changes to the medical or dental history, I will inform the practice.
*
I have received access to the
KFO HIPAA Notice of Privacy Practices
. This notice is also available on request at the office.
I authorize Kelly Family Orthodontics to discuss personal treatment and finances with the following individual(s):
*
Authorization to Release Information. I hereby authorize any Dentist, Physician, Hospital, Pharmacy, Insurance Company, Employer or Organization to release any information regarding the medical or dental history, treatment or benefits payable for this claim to The Plan Administrator or its authorized agent for the purpose of treatment and/or validating and determining benefits payable in connection with insurance claims. Data may be extracted for statistical, audit and verification purposes. I understand that I may request to receive a copy of this authorization.
*
Authorization to Pay Benefits to a Dentist. I hereby authorize any orthodontic insurance benefit to be paid directly to Kelly Family Orthodontics, PC.
*
By typing your name below, you agree that any form of electronic signature, including but not limited to signatures via facsimile, scanning, electronic mail, or a typed signature, may substitute for the original signature and shall have the same legal effect as the original signature. If you do not consent to using a typed signature, please cancel out of this form and contact our office to receive paper forms
Signature
Date