Confidential Patient Information

First Name:
Middle Initial:
Last Name:
I prefer to be called:
Sex:
Age:
Birthdate:
Social Security:
Driver's License
Home Address:
City:
State:
Zip:
Cell Phone:
Email:
Marital Status:
Whom may we thank for referring you to our office?
Names of other family members treated by our office:
Occupation:
Employer:
# of Years:
Employer Address:
Work Phone:
Spouse's Name:
Birthdate:
Work Phone:
Social Security #:
Occupation:
Employer:
# of Years:
Person Responsible for Account (if different from above)
Name:
Birthdate:
Address:
City:
State:
Zip Code:
Cell Phone:
Email:
Employer:
Driver's License:

Dental Insurance

Orthodontic Insurance?
Primary Insured's Name:
ID # or Social Security:
Birthdate:
Insurance Carrier:
Group #:
Insurance Company Address:
Phone:
If applicable:
Secondary Insured's Name:
ID # or Social Security:
Birthdate:
Insurance Carrier:
Group #:
Insurance Company Address:
Phone:

Dental History

Date of last dental check‐up:
Dentist Name:
Have you ever been treated for periodontal disease (gum disease)?
Have there been any injuries to the face, mouth or teeth?
If yes, please explain and give the approximate date:
Do you grind your teeth?
Do you experience frequent headaches, jaw aches (TMJ) or facial pain?
If yes, please explain:
How often do they occur?
If other, please explain:
Have you received treatment for this condition?
Are you still undergoing treatment?
With Whom?
Have you previously had an orthodontic consultation or treatment?
If yes, when and with whom?
Are you a mouth breather?
Do you have sleep disordered breathing or snoring?
If yes, please explain:
Please give your reasons for having an orthodontic consultation:

Medical History

Date of last physical exam:
Name/city of your doctor:
Does the Patient have any of the following? Check all that apply
Allergies to:
Are you presently taking or have ever taken medication for cancer or osteoporosis?
If yes, please list drugs and dates:
Are you required to pre‐medicate prior to dental visits?
Are you pregnant?
Please describe any current medical treatment, impending operations, or any other medical information that may possibly affect your orthodontic treatment:

General Information

Names and ages of children:
How do you like to spend your free time?

Privacy Notice

Your protected health (i.e., individually identifiable information, such as names, dates, phone numbers, email addresses, home addresses, social security numbers and demographic data) may be used or disclosed by us in one or more of the following respects:
  • To other health care providers (i.e., your general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you (i.e., to determine the results of cleanings, surgery, etc.)
  • To third party payors or RP's (i.e., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e., to determine benefits, dates of payments, etc.)
  • To certifying, licensing and credentialing bodies (i.e., the American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation
  • Internally, to all staff members who have any role in your treatment
  • To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling, etc.
  • We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you. Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke
Under the new privacy rules, you have the right to:
  • Request restrictions on the use and disclosure of your protected health information
  • Request confidential communication of your protected health information through asking us
  • Inspect and obtain copies of your protected health information through asking us
  • Amend or modify your protected helath information in certain circumstances
  • Receive an accounting of certain disclosures made by us of your protected health information
  • You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our Privacy Contact person at our office address) or the United States Secretary of Health and Human Services (which must be filed within 180 days of the violation)
We have the following duties under the privacy rules:
  • By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information
  • To abide by the terms of our Privacy Notice that is currently in effect
  • To advise you of our right to change the terms of this Privacy Notice and to make the new notice provisions effective for all protected health information maintained by us, and if we do so, we will provide you with a copy of the revised Privacy Notice
Please note that we are not obligated to:
  • Honor any request by you to restrict the use or disclosure of your protected health information
  • Amend your protected health information if, for example it is accurate and complete
  • Provide an atmosphere that is totally free of the possibility that your protected health information may be accidentally overheard by other patients and third parties.
This privacy notice is effective as of the date of your signature. If you have any questions about the information in this notice, please ask for our Privacy Contact Person or direct your questions to this person at our office.

Patient Acknowledgement I hereby acknowledge I have received and reviewed a copy of this Privacy Notice. Completion of this box serves as my signature on file.
Patient:
Date:
Is there anyone else you would like us to discuss treatment or finances with (relative, caregiver)?
Name:
Date:
Name:
Date:
Name:
Date:
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA