Confidential Patient Information

First Name:
MI:
Last Name:
I prefer to be called (Nickname):
Birthdate:
Gender:
Address
Street:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell/Other Phone:
Email:
Social Security Number (US Only):
If patient is a minor, give parent's or guardian's name:
Whom may we thank for referring you to our practice?
Other family members seen by us:

Responsible Party Information

First Name:
Last Name:
Birthdate:
Residence
Address:
City:
State:
Zip:
How long at this address?
Mailing Address (if different)
Address:
City:
State:
Zip:
Home Phone:
Work Number:
Cell/Other Phone:
Email:
Social Security Number (US Only):

If patient is under 18, please complete this section.

Previous Address (less than 3 years)
Relationship to Patient:
Employer:
Occupation:
Length of Employment:

Spouse or Other Parent's First Name:
Relationship to Patient:
Employer:
Occupation:
Length of Employment:
Social Security #:
Birthdate:
Home Phone:
Work Phone:
Cell/Other Phone:
Email:

Dental Insurance Information

Insured's Name:
Insured's Social Security Number (US Only):
Insured's DOB:
Insured's Employer:
Insurance Company:
Group No.:
Subscriber ID #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Do you have dual dental coverage?
(If yes, complete information below)

Insured's Name:
Insured's Social Security Number (US Only):
Insured's DOB:
Insured's Employer:
Insurance Company:
Group #:
Subscriber ID #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:

Emergency Information

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

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.

Are you taking any medication?
Are you allergic to any medication?
Do you have a history of any major illness?
Have you had any major operations?
Have you ever been involved in a serious accident?

Please check any of the following that you have had or currently have:

Are there any medical conditions we have not discussed that you feel we should be aware of?

Dental History

General Dentist:
Date of Last Visit:
What concerns you most about your teeth??
Please check any of the following which apply to you, and add any relevant comments.

Community Relationships

Here at Thornton Orthodontics we understand the importance of giving back and supporting our communities. Tell us more about the places you have seen or heard about our practice. Thank you in advance for your feedback.

School or Special Event?
Social Media or Community?
Personal or Business Relationship
Other

Which location do you prefer to be seen at?

Appointment Scheduling Guidelines

In order to ensure quality orthodontic care, it is important that both parents and patients understand the manner in which we schedule your appointments. Our goal is to be the best part of your day and we make it our priority to value both you and your time Therefore, we make every effort to stay on or ahead of schedule. Inconveniencing your work schedule and interrupting your child's studies as infrequently as possible is very important to our entire office. Since a large portion of our patients are of school age, it is unavoidable that some school-time appointments will be necessary. We are glad to work around your child’s important classes and provide your child with school excuses for scheduled orthodontic appointments. It is important for your child to turn these into the appropriate school official. Our staff works hard to provide the finest orthodontic care using the most convenient scheduling system possible for you and your child. Because we have families of our own, we understand your scheduling concerns and will do everything we can to ensure your child’s treatment goes as smoothly as possible. • LONG APPOINTMENTS, BANDING AND BONDING: These are more detailed and technique-sensitive appointments. Therefore, these appointments will be scheduled during our quieter morning hours. • EMERGENCIES: (Pain, Swelling, or Bleeding) This usually results from trauma to the face or mouth. These patients will be seen as soon as possible and either appropriate care given or referral to another specialist provided for treatment. • REPAIRS: (Loose bands or brackets, broken archwires or ties, broken appliances or retainers) These appointments are always scheduled during school hours since they are long visits. The vast majority of your appointments over the course of treatment will be short appointments. By seeing our long-visit patients during school hours, it leaves more room in our schedule to see patients during after-school hours. • APPOINTMENTS BROKEN OR NOT CANCELLED WITHIN 48 HOURS: Another appointment will be scheduled but may require waiting four to six weeks. An appointment made during school hours may be arranged sooner. A $10 rescheduling fee is applied to appointments rescheduled without sufficient notice, as that appointment may have been needed for another family. • GENERAL DENTIST APPOINTMENTS: As treatment progresses, it is important to continue seeing your regular dentist every six months for checkup and cleaning. Please let us know when you schedule your next dental appointment and we will schedule coordinating appointments to temporarily remove your wires before the visit. Immediately after your dental visit, we will replace your wires to ensure progressive tooth movement. Thank you so very much for understanding!

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 of 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 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; and, • 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 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.

Privacy Consent

• Prior to commencing your orthodontic treatment, you should review all details of the form. • Your protected health information (i.e., individually identifiable information such as names, dates, phone/faxnumbers, email addresses, home addresses, social security numbers, and demographic data) may be used in connection with your treatment, payment of your account or health care operations (i.e., performance reviews,certification, accreditation and licensure). • You have the right to review our office's privacy notice prior to signing this Consent, a copy of which was given to you with this Consent. • You have the right to request restrictions on the use of your protected health information. However, we are not required to, and may not, honor your request. • We may amend the attached privacy notice at any time. If we do, we will provide you with a copy of the changes, and the changes may not be implemented prior to the effective date of the revised notice. • You may revoke this Consent at any time in writing. However, such revocation will not be effective to the extent that any action has been taken in reliance on this Consent. Thank you for your cooperation. Please let us know if you have any questions.

Privacy Authorization

This Authorization is required by the privacy regulations recently promulgated by the United States Department of Health and Human Services. Your protected health information, including photographs, x-rays, and study models may be used or disclosed for the purpose of: • Lectures/presentations; • Publications; • Research; • Practice Marketing; This information will be disclosed by Dr. Thornton and all team members. The information will be disclosed to others entering this office and other members of the orthodontic profession. This Authorization will expire 6 years from the date of signature below. You have the right to revoke this Authorization at any time in writing. However, your revocation will not be effective to the extent that this Authorization has been relied on. If your treatment will be used for research purposes, we may condition your treatment on obtaining this Authorization, in which case you may not receive treatment. The information used or disclosed per this Authorization may be subject to re-disclosure by the recipient(s),and thus, no longer protected by the privacy rules.

Permission to Disclose Health Information

We may disclose your health information to a family member, personal representative, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. Please list the individuals who have your permission to share your health information.

By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge and you have read and agree to all policies. All information is confidential and is accessed only via a secure, encrypted interface. I understand that, where appropriate, credit bureau reports may be obtained.