Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Preferred Name:
DOB:
Age:
Gender:
Male
Female
Other
Marital Status:
Address:
City:
State:
Zip:
Phone Number:
E-mail Address:
Preferred Method of Contact:
Text
E-mail
May we leave a detailed message?
Yes
No
Employer:
Occupation:
Spouse's Name:
Employer Name & Occupation:
Past or present family members treated by our office:
Who may we thank for referring you to our office?
Primary reason for seeking orthodontic treatment
Primary Dental Insurance
Check if no orthodontic coverage will be applied
Insurance Company:
Employer/Group Name:
Subscriber/Employee Name:
Subscriber ID/SSN:
Date of Birth:
Relationship to Patient:
Secondary Dental Insurance
Check if no secondary insurance
Insurance Company:
Employer/Group Name:
Subscriber/Employee Name:
Subscriber ID/SSN:
Date of Birth:
Relationship to Patient:
Medical History
Is the patient taking any medication?
Yes
No
Is the patient allergic to any medication/metals?
Yes
No
History of a major illness?
Yes
No
Ever been involved in a serious accident?
Yes
No
Seen a physician in the last 12 months?
Yes
No
Does the patient smoke or use smokeless tobacco?
Yes
No
Female Patients only:
Is the patient pregnant?
Yes
No
Check "Yes" or "No" on the following medical conditions below that the patient has had. Past or Present.
ADD/ADHD
Yes
No
Anemia
Yes
No
Arthritis
Yes
No
Asthma or Hayfever
Yes
No
Bone disorders
Yes
No
Congenital Heart Defect
Yes
No
Tonsils/Adenoids removed
Yes
No
Diabetes
Yes
No
Dizziness
Yes
No
Epilepsy
Yes
No
Gastrointestinal Disorders
Yes
No
Heart Disease
Yes
No
Heart Murmur
Yes
No
Hepatitis/Liver Problems
Yes
No
Herpes
Yes
No
High Blood Pressure
Yes
No
HIV / AIDS
Yes
No
Kidney Problems
Yes
No
Nervous Disorders
Yes
No
Tumor or Cancer
Yes
No
Osteopenia/Osteoporosis
Yes
No
Prolonged/Abnormal Bleeding
Yes
No
Radiation/Chemotherapy
Yes
No
Rheumatic Fever
Yes
No
Sleep Apnea/Severe Snoring
Yes
No
Speech/Hearing Problems
Yes
No
Tuberculosis
Yes
No
If any of the above questions were answered 'Yes', please explain.
Are there any medical conditions we have not discussed that you feel we should be aware of?
Dental History
Dentist Name:
Last dental visit/cleaning
Is the patient presently in any dental pain?
Yes
No
Outstanding dental treatment to be completed?
Yes
No
Is premedication required before dental procedures?
Yes
No
Anxious or nervous about dental procedures?
Yes
No
Are you aware that some appointments will be during school/work hours?
Yes
No
Has the patient seen an orthodontist before?
Yes
No
If so, when and whom?
Check "Yes" or "No" for the following dental conditions that the patient has had. Past or Present.
Nail biting
Yes
No
Thumb sucking
Yes
No
Tongue thrust
Yes
No
Mouth breathing
Yes
No
Jaw locking open or close
Yes
No
Jaw pain
Yes
No
Jaw popping/clicking
Yes
No
Clenching/Grinding
Yes
No
Check "Yes" or "No" for the following problems you are seeking treatment for.
Crowding
Yes
No
Spacing
Yes
No
Missing teeth
Yes
No
Extra teeth
Yes
No
Other
Yes
No
Records Consent and Standard Photo Release
I hereby give my permission for the use of orthodontic records, including x-rays, photographs, made in the process of examinations, treatment, and retention for purposes of professional consultations, research, education/marketing, or publication in professional journals.
Yes
No
I hereby authorize
Smiles to Love Orthodontics
to publish the photographs taken of me, and my name, for use in their printed publications, educational/marketing material, social media, and website.
I acknowledge that since my participation in publications, educational/marketing material, social media, and websites produced by
Smiles to Love Orthodontics
is voluntary, I will receive no financial compensation.
I further agree that my participation in any publication, educational/marketing material, social media, and website produced by
Smiles to Love Orthodontics
confers upon me no right of ownership whatsoever.
I release
Smiles to Love Orthodontics
, its contractors, and its employees from liability for any claims by me or any third party in connection with my participation.
Yes
No
I would like to be entered into a drawing for the chance to win a celebratory mini-session with
Lady Brio Photography
. If your name is chosen, you will receive 30 complimentary minutes of shooting time at an outdoor local location, 5+ digital images to keep, and a canvas will be hung up at
Smiles to Love Orthodontics
so everyone can see your beautiful new Smile!
If your name is drawn, you will be contacted by our office or the photographer.
Smiles to Love Orthodontics
reserves the right to publish the photographs taken of me by Lady Brio Photography, for use in their printed publications, educational/marketing material, social media, and website.
Yes
No
Signature:
Date:
Relationship to Patient:
HIPAA
Dear Patient,
In order for us to stay within the HIPAA guidelines, please list below anyone that you authorize us to disclose information to regarding your Protected Health Information. This includes step-parents, grandparents and any care takers who can have access to this patient's records. It is not mandatory that you list anyone.
(You do not need to list any of your doctors or insurance companies)
.
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Do we have your permission to leave information on your voicemail/email if we are unable to reach you?
Yes
No
What is the
best number
and
email
to contact you?
Patient's Name:
Date of Birth:
Patient or Parent/Guardian Signature:
Date:
Acknowledgement of Access to Notice of Privacy Practices
Purpose:
This form is used to obtain acknowledgement of access to our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgement.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
**You May Refuse to Sign this Acknowledgement. In refusing we may not be allowed to process your insurance claims••
Refusal to Sign
I,
(Patient Name) have read a copy of this office's Notice of Privacy Practices.
Patient or Parent/Guardian Signature
Today's Date:
Authorization and Release:
To the best of my knowledge the above questions have been accurately answered and it is my responsibility to inform this office of any changes to the patient's medical status. I give
Smiles to Love Orthodontics
permission to perform the necessary dental services that the patient may need and my information will be held in the strictest of confidence in accordance with HIPAA.
Signature of Patient or Guardian:
Date: