Patient Information

First Name:
Middle Initial:
Last Name:
Common Name:
Date of Birth:
Age:
Gender:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
School:
Patient's Hobbies/Interests:
How did you decide to come to our office?
Are there any other family members that need an exam?
Relatives or friends previously treated here:

Responsible Party Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
SSN:
Marital Status:
Address:
City:
State:
Zip:
Email:
Main Phone:
Cell Phone:
Employer:
Occupation:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
SSN:
Marital Status:
Address:
City:
State:
Zip:
Email:
Main Phone:
Cell Phone:
Employer:
Occupation:

Dental Insurance Information

Orthodontic Coverage?
Insured's Name:
Date of Birth:
Relationship to Patient:
Insured's Employer:
SSN:
Subscriber ID:
Group Number:
Insurance Company Name:
Insurance Company Phone:
Do you have dual dental coverage?
(If yes, complete information below)
Insured's Name:
Date of Birth:
Relationship to Patient:
Insured's Employer:
SSN:
Subscriber ID:
Group Number:
Insurance Company Name:
Insurance Company Phone:

Medical/Dental History

General Dentist:
Last Dental Visit:
Is the patient under the care of a physician for a specific problem at this time? If yes, please explain:
Physician's Name:
Are you taking any prescription medications?
If yes, please list all medications:
Are you currently taking a bisphosphonate for osteoporosis? If yes, which one?
List any drug sensitivities:
Do you have a medical condition that requires premedication prior to dental procedures?
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past.
Latex Allergy
Diabetes
Epilepsy
Hepatitis
Asthma
Mouth Breathing
Extracted Teeth
Speech Therapy
Jaw Joint Pain
Bone Disorders
ADD/ADHD
AIDS/HIV
Ear/Tonsil Issues
Face,Mouth or Teeth Injuries
Family History of Underbite
Thumb/Finger Sucking Habit
Teeth Grinding
Heart Condition
Kidney Problems
Endocrine Problems
Emotional Problems
Smoker
Tobacco Use
Vaping
List any other serious medical issues:
List any allergies:

Patient Preferences

Patient's attitude toward orthodontic treatment?
Has the patient had an orthodontic consult or treatment?
If orthodontic treatment is recommended, which payment plan option would be most appealing to your family?
What orthodontic option interests you most? (Check all that apply)
How soon do you want to get started?
Signature of Patient/Parent/Guardian:
Date:

Photo Consent

On occasion, Wedding Thompson Orthodontics takes photos to showcase our extraordinary patients, before and after smile results, and other fun events on our website and our social media pages. We would love your permission to use these images taken of you/your child.

Signature of Patient/Parent/Guardian:
Date:

HIPAA 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 respects:

  • 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, etc.);
  • 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 or certain disclosures made by us of your protected health information; and,
  • You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us ( by submitting inquires 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 this 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 over heard 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 of Patient/Parent/Guardian:
Date: