Confidential Patient Information

First Name:
MI:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
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 in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?

Financial Party Information

First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Birthdate:
Address:
City:
State:
Zip:
How long at this address?
Previous Address (less than 3 years)
Email:
Main Phone:
2nd/Cell Phone:
Work Phone #:
Social Security #:
Employer:
Occupation:
Length of Employment:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Social Security #:
Birthdate:
Employer:
Occupation:
Length of Employment:
Work Phone #:

Dental Insurance Information

I give permission to GO Orthodontics to verify and file the insurance provided for payment.
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Policy Holder's Address:
Insurance Company:
Subscriber ID/SS#:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Date of Birth:
Do you have dual dental coverage?
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Policy Holder's Address:
Insurance Company:
Subscriber ID/SS#:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Date of Birth:

Emergency Information

Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:

Dental History

General Dentist:
What concerns the patient most about their teeth?
Please check any of the following which apply to you, and add any relevant comments.
Comment:
Comment:
Comment:
Comment:
Comment:
Comment:
Comment:
Comment:
Comment:
When was your last visit/cleaning with your general dentist?
Do you have any of the following dental care scheduled in the near future? If yes, check all that apply.
Comment:

Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.
Physician:
Date of Last Visit:
Please check any of the following which apply to you, and add any relevant comments.
Comment:
Comment:
Comment:
Comment:
Comment:
Please check any of the following the patient has had or currently has:
Comment:
Are there any medical conditions we have not discussed that you feel we should be aware of?

Patient Motivation for Orthodontic Treatment

Patients often request changes in their bites or faces and relief from pain or discomfort. Please help us to understand your concerns by checking the following information; please be specific (check the words - upper, lower, more, etc.)

Teeth - If your teeth could be changed, how would you like them to change?

Face - If your facial appearance could be changed, what would you change?

Symptoms - If you want to reduce pain or discomfort, please be specific about its location; check the right or left side or both if they apply.

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Height:
Weight:
School:
Grade:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Has either biological parent ever had orthodontic treatment:

HIPAA Privacy Acknowledgement

Please click here to view the GO Orthodontics HIPAA Privacy Practices.

Patient Authorization for Specific Disclosure of Protected Health Information:

Whom would you like to be able to receive protected health information about you?
Name:
Phone Number:
Relationship to Patient:
Address:
City:
State/Province:
Zip/Postal Code:
What information would you like them to have?
Additional person to be able to receive your protected health information:
Name:
Phone Number:
Relationship to Patient:
Address:
City:
State/Province:
Zip/Postal Code:
What information would you like them to have?
Do you understand that you may revoke the authorization at any time?
Do you understand this authorization may expire in 90 days?
Do you understand GO Orthodontics may not condition treatment on whether you sign this form?
You may request a full disclosure of your rights as to your PHI at any time.
Please type your signature below. Typed signature shall serve as a written signature in this instance.
Signature:
Date: