Confidential Patient Information

Patient's Last Name:
Patient's First Name:
Patient's Middle Name:
Home phone:
Work phone:
Cell/other phone:
Social Security #:

Spouse's Name:
Work Phone:
Spouse's Social Security #:
Spouse's Birthdate:
Spouse's Employer:
Whom may we thank for referring you to our office?


Subscriber’s Name:
Member ID or SSN # :
Subscriber Date of Birth:
Group No.
Insurance Company:
Phone No.:
Insurance Co. Address:
Do you have dual coverage?
Subscriber’s Name:
Member ID or SSN # :
Subscriber Date of Birth:
Group No.
Insurance Company:
Phone No.:
Insurance Co. Address:


Name of nearest relative not living with you:
Complete address:
Relationship to Patient:


Why are you seeking orthodontic treatment? (Please be as specific as possible) :
General Dentist:
Date of last visit:
Are you presently in any dental pain?
Have there been any injuries to face, mouth, or teeth?
Do you have any type of thumb or tongue habit?
Have you ever seen an orthodontist? If yes, who and when?
What is your attitude toward receiving orthodontic treatment?
Has anyone in your family received orthodontic treatment?
How did they feel about the result?
Are you aware of your jaw clicking or popping?
Have you ever been told that you grind your teeth?
Do you have “tension” headaches?
Are you aware that some appointments will be during work hours?
If any of the above questions were answered 'yes', please explain.


Date of Last Visit :
Are you taking any medication?
Are you allergic to any medication?
Do you have a history of a major illness?
Do you need to be premedicated for routine dental procedures?
Have you had any operations?
Have you seen a physician in the last 12 months?
Female Patients Only: Are you pregnant?
If any of the above questions were answered 'yes', please explain.
Check any of the medical conditions below that you have had or currently have:
Are there any medical conditions we have not discussed that you feel we should be aware of?
I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Scott Huang or Dr. Jane Lu to perform a complete orthodontic evaluation


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 whether 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, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to 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 Practices, 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:

Contact Person: Office Manager
Telephone: 832-539-6388
Address: 5418 Highway 6, Suite 215, Missouri City, TX 77459

Right to Revoke: You will have the right to revoke this Consent at any time by giving us 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.

I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.
If this Consent is signed by a personal representative on behalf of the patient, complete the following:
Personal Representative’s Name:
Relationship to Patient: