Confidential Patient Information

Welcome and thank you for choosing Rigali, Walder & Haughey Orthodontics. Please fill out this form completely. If you have any questions or need assistance, please ask.
* First Name:
Middle Initial:
* Last Name:
Nickname:
* Patient Birthdate:
* Home Phone:
* Address:
* City:
* State:
* Zip:
Email:
Age:
* Sex Assigned at birth:
* Pronouns:
Student?
Spouse or Parent's name:
Patient's or Parent's employer:
Work Phone:
* Person to contact in case of emergency:
* Phone:
Reason for seeking orthodontic treatment:
Who referred you to our office?
General dentist's name:
Date of last cleaning:
Were x-rays taken?

Responsible Party and Insurance Information

* First Name:
Middle Initial:
* Last Name:
Relationship to Patient:
* Address:
* City:
* State:
* Zip:
Email:
Home Phone:
Cell Phone:
SSN:
Do you have insurance that covers orthodontics?
Name of insured:
Insured date of birth:
Name of insurance company:
Group #:
Policy #:
Insurance company address:
City:
State:
Zip:

Medical and Dental History

Have you been under the care of a physician during the past 2 years?
If yes, for what reason?
Present medications (including non-prescription medications):
Allergies:
antibiotics?
If yes, which antibiotic(s):
latex rubber?
metals?
If yes, which metal(s):
List other allergies:
Do you use tobacco?
Do you use other controlled substances?
Have you ever had any periodontal or gum problems?
Are you now or have you ever been under the care of a periodontal specialist?
Have there been any injuries to the face, mouth, or teeth?
Have you had any head, neck, or jaw injuries?
Have you had any TMJ or jaw problems, such as clicking or pain?
Have you had orthodontic treatment in the past?
How would you rate you/your child's tolerance for discomfort (1 through 10 with 10 being the least able to tolerate any minor discomfort?)
For women: Are you pregnant or think you may be pregnant?
For children and teens:
Has the patient reached puberty? Girls:menstruation
Has the patient reached puberty? Boys:voice change
Has the patient ever sucked a thumb, finger or a pacifier?
If yes, which one (thumb, finger, pacifier):
Does the patient have any speech problems?
Patient's hobbies and interests:
Do you currently have, or had in the past any of the following?
Heart disease
Rheumatic fever
Epilepsy
Thyroid problem
Heart attack
High blood pressure
Kidney condition
Glaucoma
Heart murmur
Stroke
Asthma
Psychiatric treatment
Damaged heart valves
Blood disorder
Emphysema
HIV/Aids
Mitral valve prolapse
Anemia
Tuberculosis
Sexually transmitted disease
Artificial valves
Cancer/tumor
Fainting
Drug abuse
Chest pain
Diabetes
Sinus problem
Artificial joint
Hepatitis
Jaundice
Stomach trouble/ulcer

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to relase any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to Rigali, Walder & Haughey Orthodontics insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

* Signature of patient (or parent if patient is a minor):
* Date:

Acknowledgment of Receipt of The Privacy Notice

I acknowledge that I have been provided with a copy of the HIPAA Rigali, Walder & Haughey Orthodontics privacy notice.

* Signature of patient (or parent if patient is a minor):
* Date: