Please fill out all paperwork below prior to your first appointment.

Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Main Phone:
2nd/Cell Phone:

Please list the names of any friends or family currently in the practice:
Whom may we thank for referring you to our practice?

Financial Party Information

First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Main Phone:
2nd/Cell Phone:
Do you have insurance that covers orthodontics?
If so, please name the Insurance Company:
Length of Employment:
Work 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?

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?
Discomfort from teeth or gums?
Pain, tenderness or noise in either jaw?
Frequent headaches?
Oral habits (thumb/finger sucking, lip/nail biting)?
Neck/shoulder pain?
Frequent sore throats?
Brush teeth daily?
Floss teeth daily?
Fluoride treatments?
Mouth breathing?
Snores during sleep?
Requires premedication?
Any missing or extra permanent teeth?
Apprehensive about dental care?
Frequently Chew Gum?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of Last Physical:
Patient Health:
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
Rheumatic Fever
Tuberculosis/Lung Disease
Liver Disease
Kidney Disease
Heart Attack/Stroke
Heart Disease
Congenital Heart Defect
Heart Murmur
Thyroid Issues
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Tonsils/Adenoids Removed
Family History of Cancer
Received Radiation Treatment
Growth Problems
Endocrine Problems
Hormone Therapy
Latex/Metal Allergy
Nervous Disorders
Bone Disorders/Bone Loss
Treated for Emotional Problems
Ever Been Hospitalized
Take Bisphosphonates (Fosamax, Boniva)
If any of the above medical questions were answered 'Yes' , please explain:

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:

Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment:

Photo Release Waiver

Smile Studio Orthodontics would like to your permission to use images taken of you / your child to showcase extraordinary before and after smiles on our website, social media pages and office bulletin board. We will not use these pictures anywhere else, unless we ask for permission.

Consent for Use and Disclosure of Health Information (HIPAA)

Section B: Patients, Please Read the Following Statements Carefully

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide to sign this Consent. Our notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your protected health information. A copy of our Notice is available at your request in our office. We encourage you to request a copy and read it carefully and completely before signing this consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

Dr. Rizwan Khan
5434 W. Grand Parkway South #200 Richmond, TX 77406

Right to Revoke: You will have the right to revoke this Consent at any time by providing our office with a written notice of your revocation submitted to the contact person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

Consent: I have had full opportunity to read and consider the contents of this consent form and your Notice of Privacy Practices. I understand by signing this Consent form, I am giving my consent to use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.
Signature of Patient / Guardian:
If this Consent is signed by a personal representative on behalf of the patient, please complete the following:
Name of Personal Representative:
Relationship to Patient:
You are entitled to a copy of this consent after you sign it.

Please complete for all other children under 18 years old, no referral is needed.

The American Association of Orthodontists recommends getting an orthodontic screening for your child starting at the age of 7 years old. This allows Dr. Khan to screen for developing problems (underbites, crowding, missing teeth, etc.) that are easier to correct when the child is younger and sometimes not possible to correct when older. We offer this screening as a free exam and it consists of a full orthodontic evaluation to discuss how your child’s teeth are developing and growing. If you have any other children between the ages of 7 and 18 years old who you would like to have evaluated, please indicate their names below: