Confidential Patient Information

First Name:
Middle Initial:
Last Name:
I prefer to be called:
Sex:
Age:
Birthdate:
School:
Grade:
Home Address:
City:
State:
Zip:
Mom Cell:
Dad Cell:
Preferred Email:
What sports/activities do they participate in?
Names of other family members treated by our office:

Custodial Parent / Guardian

First Name:
Middle Initial:
Last Name:
Birthdate:
Marital Status:
Relationship to Patient:
Cell Phone:
Social Security #:
Driver's License #:
Occupation:
Employer:
# of Years:
Employer Address:
Work Phone:
Spouse's Name:
Birthdate:
Relationship to patient:
Work Phone:
Social Security #:
Occupation:
Employer:
# of Years:

If other parent is at a different address
Name:
Birthdate:
Relationship to patient:
Work Phone:
Social Security #:
Occupation:
Employer:
# of Years:

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

Whom may we thank for referring you to our office?
Did your dentist recommend an orthodontic evaluation?
Date of last dental check‐up:
Name and city of your chid's dentist:
Does your child still suck their thumb, finger, or lip (habit)?
Have there been any injuries to the face, mouth or teeth?
If yes, please explain and give the approximate date:
Does the patient have any speech problems?
Does your child grind their teeth?
Do they experience frequent headaches, jaw aches (TMJ) or facial pain?
If yes, please explain:
How often do they occur?
If other, please explain:
Has your child received treatment for this condition?
Are they still undergoing treatment?
With Whom?
Has your child previously had an orthodontic consultation or treatment?
If yes, when and with whom?
Is your child a mouth breather?
Does the patient 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/pediatrican:
Does your child have any of the following? Check all that apply
Allergies to:

Is your child required to pre‐medicate prior to dental visits?
Please indicate any medication(s) that your child is presently taking:
Is the patient presently taking or has ever taken cancer medications?
If yes, please list drugs and dates:
Please describe any current medical treatment, impending operations, or any other medical information that may possibly affect your child's dental treatment:

General Information

Names and ages of other children:
How does your child like to spend their 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 health 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 that I have received and reviewed a copy of this Privacy Notice. Completion of this box serves as my signature on file.
Parent or Guardian:
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