Confidential Patient Information
Patient's Last Name:
Patient's First Name:
Patient's Middle Name:
Address:
City:
State:
Zip:
Nickname:
Birthdate:
Social Security #:
School:
Sports/Hobbies:
Whom may we thank for referring you to our office?
RESPONSIBLE PARTY INFORMATION
Last Name:
First Name:
Middle Name:
Address:
City:
State:
Zip:
Home phone:
Work phone:
Cell/other phone:
Social Security #:
Birthdate:
Relationship to Patient:
Employer:
Occupation:
Email Address:
Spouse's Name:
Relationship to Patient:
Spouse's Social Security #:
Spouse's Birthdate:
Work Phone:
Spouse's Employer:
Occupation:
DENTAL INSURANCE INFORMATION
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?
Yes
No
Subscriber’s Name:
Member ID or SSN # :
Subscriber Date of Birth:
Group No.
Insurance Company:
Phone No.:
Insurance Co. Address:
EMERGENCY INFORMATION
Name of nearest relative not living with you:
Complete address:
Phone:
Relationship to Patient:
DENTAL HISTORY
Why is your child seeking orthodontic treatment? (Please be as specific as possible):
General Dentist:
Date of Last Visit:
Is the patient presently in any dental pain?
Yes
No
Have there been any injuries to face, mouth, or teeth?
Yes
No
Any type of thumb or tongue habit?
Yes
No
Has the patient ever seen an orthodontist? If yes, who and when?
Yes
No
What is the patient's attitude toward receiving orthodontic treatment?
Yes
No
Has anyone in the family received orthodontic treatment?
Yes
No
How did they feel about the result?
Experience jaw clicking or popping?
Yes
No
Experience “tension” headaches?
Yes
No
Is the patient sensitive or self-conscious about his/her teeth?
Yes
No
Are you aware that some appointments will be during school hours?
Yes
No
If any of the above questions were answered 'yes', please explain.
MEDICAL HISTORY
Physician:
Date of Last Visit:
Address:
Phone:
Is the patient taking any medication?
Yes
No
Is the patient allergic to any medication?
Yes
No
History of a major illness?
Yes
No
Ever been involved in a serious accident?
Yes
No
Has the patient had any operations?
Yes
No
Has the patient seen a physician in the last 12 months?
Yes
No
Is the patient pregnant?
Yes
No
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:
Abnormal bleeding
Diabetes
Hepatitis/Liver problems
Pneumonia
Anemia
Dizziness
Herpes
Prolonged Bleeding
Arthritis
Epilepsy
High Blood Pressure
Radiation/Chemotherapy
Asthma or Hayfever
Gastrointestinal Disorders
HIV / Aids
Rheumatic Fever
Bone Disorders
Heart Problems
Kidney problems
Tuberculosis
Congenital Heart Defect
Heart Murmur
Nervous Disorders
Tumor or Cancer
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
Signature:
Date:
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
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
E-mail:
info@scottandjane.com
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.
Signature:
Date:
If this Consent is signed by a personal representative on behalf of the patient, complete the following:
Personal Representative’s Name:
Relationship to Patient: