Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Preferred Name:
Age:
Date of Birth:
Gender:
Is the patient adopted?
Phone Type:
Phone:
Home Address:
City:
State:
Zip:
Patient's School/Employer
Grade/Position
General Dentist:
How did you hear about our office?
Has Davies Orthodontics treated another member of your family?
If yes, please name:
Have you visited another orthodontist before?
If yes, for what reason?
What are the main concerns you would like addressed? (check all that apply)
What is your treatment preference?
If other:
How soon would you like to start?
What is your top priority?
Person Filling Out Form:
Relationship to Patient:

Responsible Party 1

First Name:
Middle Initial:
Last Name:
Marital Status
Relationship to Patient:
Gender:
Date of Birth:
Address:
City:
State:
Zip:
Email:
Phone:
Type:
2nd Phone:
Type:
Work Phone #:
Employer:
Occupation:
If this responsible party is the subscriber for the DENTAL insurance, please fill out the following information.
Insurance Company:
Insurance Co. Phone No.:
Insurance Co. Address:
City:
State:
Zip:
Subscriber ID #:
Group No.:

By typing my name below, I acknowledge that I am signing this form and hereby authorize release of any information related to insurance claims.
Signature:
Date:

Responsible Party 2

First Name:
Middle Initial:
Last Name:
Marital Status
Relationship to Patient:
Gender:
Date of Birth:
Address:
City:
State:
Zip:
Email:
Phone:
Type:
2nd Phone:
Type:
Work Phone #:
Employer:
Occupation:
If this responsible party is the subscriber for the DENTAL insurance, please fill out the following information.
Insurance Company:
Insurance Co. Phone No.:
Insurance Co. Address:
City:
State:
Zip:
Subscriber ID #:
Group No.:

By typing my name below, I acknowledge that I am signing this form and hereby authorize release of any information related to insurance claims.
Signature:
Date:

Medical and Dental History

Patient's Physician:
Currently under the care of a physician?
If yes, for what reason?
Does the patient require premedication/antibiotics before dental treatment?
If yes, please explain:
Currently taking medication? (include non-prescription)
If yes, please list:
Any sensitivities or allergies to the following?
Please select Y (yes) or N(no) for the following questions. Your answers are for our records only and will be considered confidential. CANNOT BE BLANK.
Is the patient in excellent health?
Is the patient's height/weight normal for his/her age?
Heart murmur or damaged/artificial heart valves
Respiratory problems or Sinus trouble
Birth defects
Thyroid or endocrine problems
Diabetes
Fainting spells or seizures
Frequent colds or sore throats
Radiation or chemotherapy
Mental health problems or nervous disorder
Tonsils or adenoids removed? At what age?
Epilepsy or other neurological disease
Frequent headaches
Abnormal bleeding or Anemia
Arthritis, joint problems, or artificial joints/limbs
Currently pregnant
Cardiovascular disease or high blood pressure
Is there a condition that was not named, please explain:
Have you been informed of any missing or extra permanent teeth?
If yes, please explain?
Has the patient ever had pain/tenderness in the jaw joint (TMJ/TMD)?
If yes, please explain?
Have there been any injuries to the patient's face, mouth or chin?
If yes, please explain?
Does/did the patient have any of the following habits/conditions?

3D Scan Information and Radiology Referral Options

CBCT (Cone Beam Computer Assembled Tomography) offers our patients enhanced diagnostic value at a significantly reduced exposure. CBCT scans can image the entire head and most of the neck. As orthodontists, we evaluate teeth, jaws and surrounding bone using CBCT’s for those limited purposes. Our training and dental license does not provide for evaluating and diagnosing outside those areas. However, since CBCT imaging can cover a broader area, we want to offer you the opportunity to have your CBCT scan read by an oral radiologist, trained and licensed to evaluate and diagnose a broader area. CBCT may show evidence of disease of the cervical spine, skull or arteries. We can refer you to a radiology group for this purpose. The cost is $125.00 which may not be covered by your insurance. Please indicate your preference below.

I understand that the information I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform Davies Orthodontics of any changes in the patient’s medical status.
Initials:
By typing my name into the box below I acknowledge it as my signature, attest that I am legal guardian and all of the preceding information I entered is accurate and true to the best of my knowledge. If there are ever changes to my health or other information, I will inform Davies Orthodontics at the next appointment.

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used, disclosed and how to get access to this information. Please review it carefully.

Your Rights: When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record: You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record: You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Office communication: We may use or disclose your health information to provide you with appointment reminders and office communications. These communications can come in the form of voicemail messages, emails, texts, letters or postcards.
Request confidential communications: You can ask us to contact you in a specific way or to send mail to a different address. We will say “yes” to all reasonable requests.
Ask us to limit what we use or share: You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect patient care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information: You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice: You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated: You can complain if you feel we have violated your rights by contacting us using the information on the last page. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

Your Choices For certain health information, you can tell us your choices about what we share: If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: Share information with your family, close friends, or others involved in your care. Share information in a disaster relief situation. If you are not able to tell us your preference, for if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission: Marketing purposes. Sale of your information. In the case of fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures: How do we typically use or share your health information?
Treat you: We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization: We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.
Bill for your services: We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues: We can share health information about you for certain situations such as: Preventing disease. Helping with product recalls. Reporting adverse reactions to medications. Reporting suspected abuse, neglect, or domestic violence. Preventing or reducing a serious threat to anyone’s health or safety
Do research: We can use or share your information for health research.
Address workers’ compensation, law enforcement, and other government requests: We can use or share health information about you: For workers’ compensation claims. For law enforcement purposes or with a law enforcement official. With health oversight agencies for activities authorized by law. For special government functions such as military, national security, and presidential protective services.
Respond to lawsuits and legal actions: We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities:
We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
For additional questions or complaints, please contact:
Davies Orthodontics | smiles@daviesortho.com | (262)542-9151 | www.daviesortho.com
2117 Corporate Dr. Suite 300, Waukesha WI 53189 | 36461 Summit Village Way, Oconomowoc WI 53066

Patient Name:
Patient's Date of Birth:
By typing my name below, I acknowledge it as my signature:
Guardian's Name:
Relation:
Date: