Patient Information
First Name:
Last Name:
Preferred Nickname:
Gender:
Male
Female
Other
Birthdate:
Address:
City:
State:
Zip:
Mobile Phone:
Alternate Phone:
Email:
Patient's Dentist Name:
Dentist City:
If a student, name of patient's school:
If currently employed, name of patient's employer:
Do you have any family or friends that have been treated at Escott Orthodontics?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
Provide information about the parent/guardian or any other person that be financially responsible for treatment.
First Name:
Last Name:
Preferred Nickname:
Gender:
Male
Female
Other
Birthdate:
Address:
City:
State:
Zip:
Cell Phone:
Alternate Phone:
Email:
Dental Insurance Information
If you would like to use insurance benefits, please provide information about your insurance plan in advance so that we can prepare an estimate of your coverage before you arrive for your visit. By verifying your benefits in advance, we can provide you with an accurate estimate for the cost of treatment during your consultation.
Check if you would like to send us a text message or email with an image of your insurance card.
Check if you would like to enter your policy details in the form below.
Insurance Company Name:
Group Number:
Subscriber ID:
Policy Holder's Employer:
Policy Holder's Name:
Patient Health Information
Indicate YES or NO for each of the questions below. Please provide additional information where requested:
Is the patient under the care of a physician at this time?
Yes
No
If yes, for what conditions?
Is the patient currently taking any prescription or over-the-counter medications? Please list all.
Medication:
Taken For:
Medication:
Taken For:
Medication:
Taken For:
Medication:
Taken For:
Medication:
Taken For:
Is the patient taking antibiotic pre-medication before any dental procedures?
Yes
No
If yes, please describe reason for pre-medication:
Has the patient ever taken any medications to strengthen his/her bones (such as Fosamax, Boniva, Prolia)?
Yes
No
If yes, please describe:
Has the patient ever taken bisphosphonate medication for bone disorders or cancer?
Yes
No
If yes, please indicate if oral or intravenous:
Does the patient smoke or chew tobacco?
Yes
No
If yes, please describe use and frequency:
Has the patient ever had speech therapy, or physical therapy associated with the head, neck or tongue?
Yes
No
If yes, please describe:
Is the patient pregnant?
Yes
No
Allergies
Is the patient known to have allergies or a history of past allergic reactions to any of the following:
latex (gloves, balloons)
Yes
No
other antibiotics
Yes
No
please describe:
metals (jewelry, clothing snaps)
Yes
No
local anesthetics (e.g. novocaine, lidocaine, xylocaine)
Yes
No
aspirin
Yes
No
acrylics
Yes
No
ibuprofen (Motrin, Advil)
Yes
No
foods
Yes
No
please describe:
penicillin
Yes
No
other substances
Yes
No
please describe:
Medical History
Now, or in the past, has the patient had any of the following:
any injuries to face, head, neck?
Yes
No
kidney problems?
Yes
No
asthma, sinus problems, hay fever?
Yes
No
cancer, tumor, radiation treatment or chemotherapy?
Yes
No
tonsil or adenoid condition?
Yes
No
stomach ulcer, hyperacidity, acid reflux?
Yes
No
a tendency to frequently breathe through the mouth?
Yes
No
immune system problems?
Yes
No
frequent ear infections, colds, throat infections?
Yes
No
history of osteoporosis?
Yes
No
vision, hearing, or speech problems?
Yes
No
skin disorder (other than common acne)?
Yes
No
bone fractures, or major injuries?
Yes
No
hepatitis, jaundice, or other liver problem?
Yes
No
diabetes or low sugar?
Yes
No
AIDS or HIV?
Yes
No
arthritis or joint problems?
Yes
No
mononucleosis, tuberculosis, pneumonia, or polio?
Yes
No
seizures, fainting spells, neurologic problems?
Yes
No
mental health disturbance or depression?
Yes
No
history of eating disorder (anorexia, bulimia)?
Yes
No
high or low blood pressure?
Yes
No
heart defects, heart murmur, rheumatic heart disease?
Yes
No
excessive bleeding or bruising, anemia?
Yes
No
endocrine or thyroid problems?
Yes
No
chest pain, shortness of breath, tire easily, swollen ankles?
Yes
No
birth defects or hereditary problems?
Yes
No
angina, arteriosclerosis, stroke, or heart attack?
Yes
No
Other Conditions or Concerns
Is there any other medical condition or concern we should be aware of?
Yes
No
If yes, please describe:
I have read all of the above questions and understand them. To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to the health of the patient. I will not hold the doctor or any member of the staff responsible for any errors or omissions that I have made in the completion of this form. I will notify the doctor of any changes in the patient's medical or dental health. I hereby give permission to Escott Orthodontics to treat the patient.
Patient Name:
Signature of Patient or Parent/Guardian:
Date:
PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
You may refuse to sign this acknowledgement & authorization. In refusing we
may not be allowed
to process your insurance claims.
Date:
PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:
This includes spouses, step parents, grandparents and any other family members or care takers who you would like us to be able to communicate with about the patient’s treatment.
Name:
Relationship:
Name:
Relationship:
I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, and for TREATMENT
Phone
Text Message
Email
Any of the above
I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA:
Phone:
Text Message
Email
Any of the Above
DO YOU HAVE A PREFERENCE IN HOW YOU WANT TO BE ADDRESSED WHEN SUMMONED FROM THE RECEPTION AREA:
First Name Only
Proper Surname
Other
The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. The undersigned authorizes release of any information regarding the patient’s orthodontic treatment to his/her dental and/or medical insurance company. My signature will also serve as a Protected Health Information document release should a request be made to send treatment information or radiographs to another attending doctor or facility in the future. A copy of this signed document shall be as effective as the original.
Name of Patient:
Signature of Patient / Guardian of Patient:
Guardian / Legal Representative:
Relationship of Guardian / Legal Representative:
In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.
Your Health Information Rights
Although your health record is the physical property of this office, you have the following rights with respect to your health information:
You may request that we not use or disclose your health information for a particular reason related to treatment, payment, our general healthcare operations, and/or to a particular family member, other relatives or close personal friend. We ask that such requests be made in writing on a form provided by us. Although we will consider your request, please be aware that we are under no obligation to accept it or to abide by it, except as provided below.
If you have paid for services out-of-pocket in full, you may request that we not disclose information related solely to those services to your health plan. We ask that such requests be made in writing on a form provided by us. We are required to abide by such a request, except where we are required by law to make a disclosure. We are not required to inform other providers of such a request, so you should notify any other providers regarding such a request.
You have the right to receive confidential communications from us by alternative means or at an alternative location. Such a request must be made in writing, and submitted to the Privacy Officer. We will attempt to accommodate all reasonable requests.
You may request to inspect and/or obtain copies of health information about you, which will be provided to you in the time frames established by law. If we maintain your health information electronically in a designated record set, you may obtain an electronic copy of the information. If you request a copy (paper or electronic), we will charge you a reasonable, cost-based fee.
If you believe that any health information in your record is incorrect, or if you believe that important information is missing, you may request that we correct the existing information or add the missing information. Such requests must be made in writing, and must provide a reason to support the amendment. We ask that you use the form provided by us to make such requests. For a request form, please contact the Privacy Officer.
You may request that we provide you with a written accounting of all disclosures made by us during the time period for which you request (not to exceed six years), as required by law. We ask that such requests be made in writing on a form provided by us. Please note that accounting does not include all disclosures, e.g., disclosures to carry out treatment, payment, or healthcare operations and disclosures made to you or your legal representative or pursuant to an authorization. You will not be charged for your first accounting request in any 12-month period. However, for any requests that you make thereafter, you will be charged a reasonable, cost-based fee.
You have the right to be notified following a breach of your unsecured protected health information.
You have the right to obtain a paper copy of our Notice of Privacy Practices upon request.
For More Information or to Report a Problem
We will follow our rules as set forth in this Notice. If you want more information or if you believe your privacy rights have been violated we want to make it right. We never will penalize you for filing a complaint. To do so, please file a formal, written complaint within 180 days with:
The U.S. Department of Health & Human Services, Office of Civil Rights
200 Independence Ave., S.W.
Washington, DC 20201
Or, submit a written complaint form to us at the following address:
Escott Orthodontics
16821 US Highway 441
Mount Dora, FL 32757
If you have any questions or want more information about this Notice of Privacy Practices, please contact our Privacy Officer.
Signature of Patient or Parent/Guardian/Representative:
Date:
i-CAT 3D IMAGING INFORMATION
Escott Orthodontics utilizes advanced 3D imaging to improve planning for orthodontic treatment and to complement the advanced orthodontic treatment methods that we utilize.
WHAT IS 3D CBCT IMAGING?
These images are acquired through i-CAT Cone Beam Computer Assembled Tomography (CBCT). This technology is sometimes referred to as 3D x-rays. Using CBCT scans means we have the ability to take 3D images of teeth, jaws, and facial structures with significantly less x-ray exposure than a typical CT scan used in hospitals.
This CBCT imaging is included in your orthodontic consultation and treatment at no additional fee.
UNDERSTANDING THE OPTION FOR RADIOLOGIST REVIEW
At Escott Orthodontics, CBCT scans are utilized for the limited purpose of evaluating teeth, jaws and facial structures for orthodontic treatment. Our dental specialty training is not sufficient for evaluating and diagnosing outside those areas. However, CBCT imaging can reveal a broad spectrum of medical conditions and pathology, including evidence of disease of the skull, TMJ, cervical spine, or arteries. Therefore, we offer each patient the opportunity to have a CBCT scan read by a radiologist trained and licensed to evaluate and diagnose a broader area. If elected, the cost for this service may not be covered by your insurance. This fee includes radiologist review of the patient’s CBCT scan, and a written report of radiologist findings. Our office will manage all necessary steps to submit the scan for radiologist review, and we will provide you a written summary of the findings once available from the radiologist. If you are interested in this service, please indicate YES in the consent form below.
RADIOLOGIST REVIEW CONSENT or WAIVER
The patient acknowledges he/she has been informed that CBCT scans are made at Escott Orthodontics for the sole purpose of planning orthodontic treatment and are not reviewed for any other diagnostic purposes. The patient acknowledges that he/she understands the doctors and employees of Escott Orthodontics are not trained radiologists and are not qualified to diagnose many conditions, pathology, or other findings that may be revealed on a CBCT scan. The patient acknowledges he/she has been given the option to forward the CBCT scan to a licensed radiologist for review at the cost of $149.00. The patient has elected one of the two options below:
YES
, I request that the CBCT scan be forwarded to a licensed radiologist for further review, interpretation, and diagnosis. I understand that I am responsible for the extra cost of this service.
NO
, I decline the option to forward my CBCT scan for further interpretation, diagnosis and review by a licensed radiologist. I understand the benefits of having my CBCT read and interpreted by a licensed radiologist; however, I knowingly decline the referral. I understand the risks associated with a failure to diagnose conditions, pathology, or other findings that may be revealed on a CBCT scan due to my decision to decline this referral. On behalf of myself/my child, and all those who may now or in the future have any interest in the care and treatment for myself/my child, now and forever release and discharge Dr. Christopher Escott and Escott Orthodontics, as well as all associated doctors, employees, agents, professional corporation, insurers and assigns from any loss, costs, damages or expenses arising out of the decision to decline review, evaluation, and diagnosis of the CBCT scan.
PATIENT NAME:
SIGNATURE of PATIENT or PARENT/GUARDIAN:
DATE: