Confidential Patient Information
First Name:
MI:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Cell Phone:
2nd/Cell Phone:
Email:
School:
If patient is a minor, give parent's or legal guardian's name:
Please list the names of any friends or family currently in the practice:
How did you find out about 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:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Address:
City:
State:
Zip:
Email:
Cell Phone:
Home Phone:
Social Security #:
Driver's License #:
Issuing State:
Employer:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Social Security #:
Birthdate:
Employer:
Cell Phone:
Dental Insurance Information
Do you have dental insurance?
No
Yes
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Insurance Company:
Subscriber ID # or Social Security #:
Subscriber's Date of Birth:
Group No.:
Plan ID#:
Insurance Co. Phone No.:
Do you have dual dental coverage?
No
Yes
(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 # or Social Security #:
Subscriber's Date of Birth:
Group No.:
Plan ID#:
Insurance Co. Phone No.:
Emergency Information
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Dental History
Dentist Name:
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.
Clench or Grind Teeth?
No
Yes
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
Injury to face, jaw, teeth or mouth?
No
Yes
Previous periodontal (gum) treatment?
No
Yes
Brush teeth daily?
No
Yes
Floss teeth daily?
No
Yes
Fluoride treatments?
No
Yes
Thumb or finger habit as a child?
No
Yes
Bleeding gums?
No
Yes
Is all dental work completed at this time?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Do you have a history of jaw joint problems?
No
Yes
If any of the above TMJ questions were answered 'Yes', please explain:
Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Has there been any change in the patient's general health within the last year?
No
Yes
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
List any medications currently being taken by the patient (include non-prescription):
Our office is committed to meeting or exceeding the standards of infection control mandatory by OSHA, the CDC and the ADA.
Allergies or drug reaction to:
Latex
No
Yes
Nickel/Metal Allergy
No
Yes
Dental anesthetics
No
Yes
Other:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Liver Disease / Jaundice / Hepatitis
No
Yes
Hypertension/High Blood Pressure
No
Yes
Prolonged Bleeding/Transfusion
No
Yes
Anemia / Blood disorder
No
Yes
HIV/AIDS
No
Yes
Handicaps/Disabilities
No
Yes
Hepatitis
No
Yes
Sexually transmitted disease
No
Yes
FEMALES: Are you pregnant
No
Yes
Take Bisphosphonates (Fosamax, Boniva)
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
ACKNOWLEDGEMENT RECEIPT OF NOTICE OF PRIVACY PRACTICE
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
By law, we are required to provide you with our Notice of Privacy Practice. Please sign below acknowledging your receipt of this information. This shall also serve as consent to use and/or disclose your protection health information to carry out treatment, payment activities and healthcare operations.
MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR/FACILITYS IN THE FUTURE.
If you should have any questions regarding this Notice and Consent, you may contact:
ORTHODONTIC SPECIALISTS
513-772-6500
4845 Rialto Road, Suite A, West Chester, Ohio 45069
Patient, Parent, or Legal Representative's Full Name
Patient's Full Name:
Patient's Date of Birth:
Today's Date:
PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION: (This includes step parents, grandparents and any care takers who can have access to this patient’s records):
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
All parties listed on this form may have the patient's health information.
To the best of my knowledge, all of the preceding answers are true and accurate. If I (or the patient) ever have any change in health status or medications being taken or if I (or the patient) have any abnormal medical test results, I will inform the dentist at the next appointment without fail. I authorize the dental staff to perform the necessary dental serviecs the patient may need during treatment. I also auhtorize release of any information pertaining to treatment for the purpose of comprehensive filing of insurance claims. I authorize payment of primary insurance benefits directly to the dentist office otherwise payable to me. I acknowledge full responsibility for the payment of services at the time of service unless other arrangements are made with this office.