Confidential Patient Information

First Name:

Middle Initial:

Last Name:

Preferred Name:

DOB:

Gender:

Street Address:

Street Address Line 2:

City:

State:

Zip Code:

Phone:

Email:

Employer:

Occupation:

Marital Status:

Spouse's Name:

Interests:

Referred by:

Past/present family in treatment at our office? (Please list all names)

Had orthodontic consult or treatment before? Yes No

If yes, please explain:

Dental Insurance Information

Do you have dental insurance coverage? Yes No

Insurance Name:

Policy Holder's Name:

Policy Holder DOB:

Policy Holder's Employer:

ID #:

Group Number:

Insurance Company Phone:

Relationship to Policy Holder:

Medical Information/History

Dentist Name:

Last Cleaning:

Physician's Name:

Last Exam:

PLEASE CHECK ALL THAT APPLY:

Water is fluorinated

Flosses daily

Takes fluoride supplement

Brushes at least twice daily

Gums bleed

Jaw pain

PLEASE INDICATE IF YOU HAVE: (CHECK ALL THAT APPLY)

Ever received an injury to the face, mouth, teeth or chin

Had adenoids/tonsils removed

Been informed about missing or extra permanent teeeth

Been told to take antibiotics prior to dental visits

Had problems with previous dental work

Currently taking, or ever taken, a Bisphosphanate? Yes No

PLEASE CHECK ANY HABITS YOU HAVE/HAD:

Clenching/grinding

Teeth, lip sucking/biting

Mouth breathing

Nail biting

Nursing/bottle

Habit speech problem/speech therapy

Thumb/finger sucking

Tobacco use

Tongue Thrust

Used pacifier

Snoring

LIST MEDICATIONS CURRENTLY TAKING AND REASON:

ANY ALLERGIES OR REACTIONS TO ANY OF THE FOLLOWING:

Aspirin

Tylenol

Ibuprofen

Barbiturates

Codeine or other narcotics

Latex

Local anesthetics

Metals

Penicillin or other antibiotics

Plastic or vinyl

Sedatives

Sleeping pills

Sulfa drugs

Other:

PLEASE LIST ANY SERIOUS MEDICAL PROBLEMS YOU HAVE EXPERIENCED:

ANYTHING YOU WOULD LIKE TO DISCUSS WITH THE DOCTOR IN PRIVATE? Yes No

NOW OR IN THE PAST HAVE YOU HAD:

Abnormal Bleeding

Chicken Pox

Endocrine/Growth Disorder

Hepatitis

Liver Problems

Handicaps/Disabilities

Skin Rash

Tuberculosis

Anemia

Epilepsy

Cancer

HIV/AIDS

Lupus

Hemophilia/Blood Disorder

Artificial Bones/Joints

Hearing Impairment

Heart Murmur

Hives

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tire ///d /?
This refers to your usual way of life in recent times.

Even if you haven't done some of these things recently try to work out how they would have affected you.

Use the following scale to choose the most appropriate number for each situation:
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

It is important that you answer each question as best you can.

Sitting and Reading? 0 1 2 3

Watching TV? 0 1 2 3

Sitting, inactive in a public place (e.g. a theatre or a meeting? 0 1 2 3

As a passenger in a car for an hour without a break? 0 1 2 3

Lying down to rest in the afternoon when circumstances permit? 0 1 2 3

Sitting and talking to someone? 0 1 2 3

Sitting quietly after a lunch without alcohol? 0 1 2 3

In a car, while stopped for a few minutes in the traffic? 0 1 2 3

Emergency

Emergency Contact:

Relationship:

Phone number:

Patient Survey

Why are you seeking orthodontic treatment?

Who were you referred by?

How did you learn about Moody Orthodontics?

PLEASE TELL US HOW IMPORTANT THE FOLLOWING ARE TO YOU:

Please list the name, and age of any children/family members who may be interested in orthodontic treatment in our office in the future:

HIPAA

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

This notice describes how health information about you may be used. Please review it carefully. The privacy of your health information is important to us.

Our Legal Duty
We are required by applicable federal and state law to maintain the privacy of your protected health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your protected health information. This Notice will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and provide the new Notice at our practice location, and we will distribute it upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

Your Authorization: In addition to our use of your health information for the following purposes, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

Uses and Disclosures of Health Information
We use and disclose health information about you without authorization for the following purposes.

Treatment: We may use or disclose your health information for your treatment. For example, we may disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you. For example, we may send claims (filed by paper or electronically) to your dental health plan containing certain health information.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

To You Or Your Personal Representative: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to your personal representative, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information t notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, ofo your location, your general condition, or death. If you are present then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your absence or incapacity or in emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Disaster Relief: We may use or disclose your health information to assist in disaster relief efforts.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Public Health and Public Benefit: We may use or disclose your health information to report abuse, neglect, or domestic violence; to report disease, injury, and vital statistics; to report certain information to the Food and Drug Administration (FDA); to alert someone who may be at risk of contracting or spreading a disease; for health oversight activities; for certain judicial and administrative proceedings; for certain law enforcement purposes; to avert a serious threat to health or safety, and to comply with workers' compensation or similar programs.

Decedents: We may disclose health information about a decedent as authorized or required by law.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient under certain circumstances.

Release of Medical Information: We may use or disclose your health information to provide you with appointment reminders, and other important information (such as voicemail messages, text messages, emails or letters).

Questions and Complaints
If you want more information about our privacy practices or have questions or concerns, please contact us.

You may obtain a copy of our Notice of Privacy Practices, including any revision of our notice, at any time by contacting:
Contact Person: Nikki McCollum
Telephone: 512-447-6453
Email: info@moodyortho.com
Address: 2500 W William Cannon Dr #102 Austin, TX 78745