Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Street Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP Code:
If you don't have a social security number, please put all 0's.
Main Phone #:
2nd/Cell Phone #:
Email Address:
Social Security #:
If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?
Please list the names of any friends or family currently at Orthodontic Experts:
List any sports, hobbies, or musical instruments played:
How did you hear about Orthodontic Experts?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Separated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Street Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP Code:
Email Address:
Main Phone #:
2nd/Cell Phone #:
Work Phone #:
If you don't have a social security number, please put all 0's.
Social Security #:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
If you don't have a social security number, please put all 0's.
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Social Security #:
Birthdate:
Dental Insurance Information
Do you have insurance?
Yes
No
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Do you have dual dental coverage?
Yes
No
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Emergency Information
Name:
Name:
2nd/Cell Phone #:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Dental History
Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Has the patient ever had an orthodontic consult or treatment?
Yes
No
If so, when?
Does the patient need to premedicate prior to dental visit?
Yes
No
What is the patient's main orthodontic concern?
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Select here if all answers BELOW are
NO
Speech Problems/Therapy?
Yes
No
Clench or Grind Teeth?
Yes
No
Oral Habits (Thumb/Finger Sucking, Lip/Nail Biting)?
Yes
No
Injury to Face, Jaw, Teeth or Mouth?
Yes
No
Discomfort from Teeth or Gums?
Yes
No
Pain, Tenderness or Noise in Either Jaw?
Yes
No
Chipped or Injured Permanent Teeth?
Yes
No
Previous Periodontal (Gum) Treatment?
Yes
No
Mouth Breathing?
Yes
No
Apprehensive about Dental Care?
Yes
No
Do you have any pending dental work?
Yes
No
If any of the above dental questions were answered 'Yes', please explain:
Do you have a history of jaw joint problems, clicking, popping, or difficulty opening your mouth?
Yes
No
Do you have any history or current symptoms of TMJ? If yes, please describe:
Medical History
Does the patient have any allergies or drug reactions to:
Select here if all answers BELOW are
NO
Latex
Yes
No
Penicillin or Other Antibiotics
Yes
No
Sulfa Drugs
Yes
No
Aspirin, Ibuprofen, Tylenol
Yes
No
Local Anesthetics
Yes
No
Metal Allergy
Yes
No
Other:
Yes
No
List any drug allergies or sensitivities (not listed above) that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Select here if all answers BELOW are
NO
Heart Murmur
Yes
No
Damaged or Artificial Heart Valves
Yes
No
Congenital Heart Defect
Yes
No
Heart Disease
Yes
No
Rheumatic Fever
Yes
No
Angina
Yes
No
Liver Disease/Jaundice/Hepatitis
Yes
No
Kidney Disease
Yes
No
Heart Attack/Stroke
Yes
No
Hemophilia
Yes
No
Hypertension/High Blood Pressure
Yes
No
Prolonged Bleeding/Transfusion
Yes
No
Anemia/Blood disorder
Yes
No
HIV/AIDS
Yes
No
Tonsils/Adenoids Removed
Yes
No
Handicaps/Disabilities
Yes
No
Arthritis/Joint problems
Yes
No
Large Tonsils
Yes
No
Sinus Trouble
Yes
No
Bed Wetting
Yes
No
Substance Abuse Problem (Past or Present)
Yes
No
Bone Fractures/Trauma to Face/Jaw
Yes
No
Prosthetic Joints
Yes
No
Chronic Fatigue
Yes
No
Diabetes
Yes
No
Growth Problems
Yes
No
Tuberculosis or Lung Disease
Yes
No
Pneumonia
Yes
No
Cancer
Yes
No
Family History of Cancer
Yes
No
Received Radiation Treatment
Yes
No
Arteriosclerosis
Yes
No
Thyroid/Endocrine Problems
Yes
No
Stomach Ulcer or Hyperacidity
Yes
No
Hormone Therapy
Yes
No
Nervous Disorders
Yes
No
Bone Disorders/Bone Loss
Yes
No
Seizures/Epilepsy/Neurological Disease
Yes
No
Treated for Emotional Problems
Yes
No
Asthma
Yes
No
Respiratory Problems/Emphysema
Yes
No
Persistent Swollen Neck Glands
Yes
No
Sexually Transmitted Disease
Yes
No
Low Blood Pressure
Yes
No
Persistent Cough
Yes
No
Heart Condition
Yes
No
Autoimmune Disorder
Yes
No
Are you pregnant?
Yes
No
Do You Take Bisphosphonates (Fosamax, Boniva)
Yes
No
Has there been any change in the patient's general health within the last year?
Yes
No
If any of the above medical questions were answered 'Yes' , please explain:
NOTICE OF PRIVACY PRACTICES (NPP) AND ACKNOWLEDGEMENT
TO THE PATIENT—PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.
NOTICE OF PRIVACY PRACTICES:
Click here for a copy or ask and a paper copy will be provided to you.
I acknowledge that I have received the Orthodontic Experts’ Notice of Privacy Practices.
If this Acknowledgement is signed by a personal representative on behalf of the patient, complete the following:
Personal Representative’s Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Patient or Responsible Party Signature:
Date:
CONSENT FOR PHI USE, DISCLOSURE, AND EMAILING OF X-RAYS
PURPOSE OF CONSENT:
By signing this form, you consent to Orthodontic Experts use and disclosure of your protected health information (PHI) to carry out treatment, payment, and healthcare operations.
REVOCATION:
You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to our Privacy Official listed in our NPP. 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.
I have had full opportunity to read and consider the contents of this Consent form and understand that, by signing I give my consent to your use and disclosure of my protected health information to carry out treatment, payment and healthcare operations.
EMAILING X-RAYS:
To provide the best treatment to our patients, it may be necessary for us to email x-rays to other specialists or dentists. This allows other offices to have better diagnostic tools available to them.
I understand that x-rays may need to be emailed to other specialists and dentists and give my permission to do so.
Patient or Responsible Party Signature:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Date:
CONSENT FOR RECORDS
Consent to Examinations
I authorize the performance of diagnostic record examinations including, but not limited to, the following: comprehensive photos, panoramic and cephalometric x-ray images, diagnostic intraoral scan, impressions, etc.
I consent to these records for myself/my child for which Orthodontic Experts requires to evaluate orthodontic needs and determine treatment recommendations.
Release of Liability During Pregnancy
This is to certify that, to the best of my knowledge, I am not pregnant or that I consent to the capture of records during pregnancy. I give permission to Orthodontic Experts to perform diagnostic record examinations on myself/my child. I have been advised that there is an inherent risk associated with certain x-ray examinations that can be potentially harmful to an unborn child.
Patient or Responsible Party Signature:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Date:
By clicking on this box, I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of the OE staff responsible for any errors or omissions that I may have made in the completion of this form. If any changes occur to this history record or my medical or dental status, I will inform Orthodontic Experts.