Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Social Security #:
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Email:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Social Security Number:
Do you have insurance that covers orthodontics?
No
Yes
If so, please name the Insurance Company:
Employer:
Occupation:
Length of Employment:
Work Phone:
Dental History
Dentist Name:
Checkup Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
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.
Apprehensive about dental care?
No
Yes
Brush teeth daily?
No
Yes
Clench or grind teeth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Floss teeth daily?
No
Yes
Fluoride treatments?
No
Yes
Frequently chew gum?
No
Yes
Frequent headaches?
No
Yes
Frequent sore throats?
No
Yes
Injury to face, jaw, teeth, or mouth?
No
Yes
Missing or extra permanent teeth?
No
Yes
Mouth breathing?
No
Yes
Neck or shoulder pain?
No
Yes
Oral habits (thumb or finger sucking, lip or nail biting)?
No
Yes
Pain, tenderness, or noise in either jaw?
No
Yes
Requires premedication?
No
Yes
Snores during sleep?
No
Yes
Speech problems or therapy?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Address:
City:
State:
Zip:
Please list any medications currently being taken by the patient (include non-prescription):
Please list any other drug allergies or sensitivities 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.
Anemia or blood disorder?
No
Yes
Arthritis or joint problems?
No
Yes
Asthma?
No
Yes
Bisphosphonates (Fosamax, Boniva)?
No
Yes
Bone disorders or loss?
No
Yes
Cancer?
No
Yes
Cancer in family history?
No
Yes
Diabetes?
No
Yes
Emotional problems treatment?
No
Yes
Endocrine problems?
No
Yes
Growth problems?
No
Yes
Handicaps or disabilities?
No
Yes
Heart attack or stroke?
No
Yes
Heart defect (congenital)?
No
Yes
Heart disease?
No
Yes
Heart murmur?
No
Yes
Hemophilia?
No
Yes
Hepatitis?
No
Yes
High blood pressure or hypertension?
No
Yes
HIV or AIDS?
No
Yes
Hormone therapy?
No
Yes
Ever been hospitalized?
No
Yes
Kidney disease?
No
Yes
Latex or Metal Allergy?
No
Yes
Liver disease, jaundice, or hepatitis?
No
Yes
Nervous disorders?
No
Yes
Pneumonia?
No
Yes
Prolonged bleeding or transfusion?
No
Yes
Radiation treatment?
No
Yes
Rheumatic fever?
No
Yes
Seizures, epilepsy, or neurological disease?
No
Yes
Tonsils or adenoids removed?
No
Yes
Tuberculosis or lung disease?
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Patients Under 18
If patient is under the age of 18, please answer the following questions:
Please list the name and birthdate of any siblings:
Height:
Weight:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Has patient begun puberty?
No
Yes
If patient is a girl, has menstruation begun?
No
Yes
If patient is a boy, has their voice changed or have facial hair?
No
Yes
Has the patient grown in the past year or has their shoe size changed recently?
No
Yes
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative
Has either biological parent ever had orthodontic treatment:
Don't Know
Yes
No
Orthodontic Records Policy
During your first visit to our office, we typically take orthodontic records; this includes a digital scan of your/your child’s teeth, photographs, and a three-dimensional x-ray (Cone Beam CT). If you/your child starts treatment in our office, the records are included in the total cost of treatment. If you do not start treatment in our office and request a copy of your orthodontic records, a $250 records fee will apply.
PATIENT ACKNOWLEDGMENT
I hereby acknowledge that I have received and reviewed the Orthodontic Records Policy.
Signature:
Date:
Privacy Notice
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Your protected health information (i.e., individually identifiable information, such as names, dates, phone/fax 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 aspects:
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, i.e.);
To third party payors or spouses (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 payment, etc.);
To certifying, licensing and accrediting 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;
To your family and close friends involved in your treatment; and/or,
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,
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 its Privacy Notice and to make the new notice provisions effective for all protected health information maintained by us, and that 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;
or,
Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally 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 address. Thank you.
PATIENT ACKNOWLEDGMENT
I hereby acknowledge that I have received and reviewed a copy of this Privacy Notice.
Signature:
Date: