About You

First Name:
Middle Initial:
Last Name:
I prefer to be called:
Age:
Sex:
Birthdate:
Soc. Sec. #:
Driver's License #:
Home Address:
City:
State:
Zip:
Marital Status:



Cell Phone:
Email:
Whom may we thank for referring you to our office?
Names of other family members treated by our office:
Employer:
Occupation:
# Years:
Employer Address:
Work Phone:
Spouse's Name:
Employer:
Occupation:
# Years:
Soc. Sec. #:
Birthdate:
Cell Phone:

Person Responsible for Account   (if different from above)
Name:
Soc. Sec. #:
Address:
City:
State:
Zip:
Cell Phone:
Work Phone:
Employer:
Driver's License #:

Dental Insurance

Primary Insured's Name:
ID #:
Birthdate:
Primary Insurance:
Group #:
Insurance Company Address:
Phone:

Do you have dual coverage? (If yes, birthdates of each insured must be provided above)
Secondary Insured's Name:
Soc. Sec. #:
Secondary Insurance:
Group #:
Birthdate:
Insurance Company Address:
Phone:

Dental History

Date of last dental check-up:
Name and city of your dentist:
Have you ever been treated for periodontal disease (gum disease)?
Have there been any injuries to the face, mouth or teeth?
When?
Do you grind your teeth?
Do you suffer from frequent headaches, jaw aches (TMJ) or facial pain?
If so, when does it hurt?
How often does it occur?



If Other:
Have you received treatment for this condition?
Are you still undergoing treatment?
By Whom?
Have you previously had an orthodontic consultation or orthodontic treatment?
If yes, when and by whom?
Are you a mouth breather?
Do you have sleep disordered breathing, sleep apnea, or snoring?
Describe:
Please give your reasons for having an orthodontic consultation:

Patient Medical History

Date of last physical exam:
Name and city of your physician:
Do you have any of the following? Check all that apply.
Are you presently taking or have ever taken any medications for cancer or for osteoporosis?
If yes, please list drugs and dates:
Are you required to premedicate prior to dental visits?
Are you pregnant?
Please indicate any medication(s) that you are presently taking:
Please describe any current medical treatment, impending operations, or any other medical or dental information that may possibly affect your dental treatment:

General Information

Names and ages of children:
How do you like to spend your free time?

Privacy Notice

Your protected health information (i.e., individually identifiable information, such as names, dates, phone 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;
  • 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 through asking us;
  • 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 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; 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 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;
  • 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.

Patient Acknowledgement
I hereby acknowledge that I have received and reviewed a copy of this Privacy Notice.

Patient:
Date:
Is there anyone else you would like us to discuss treatment or finances with (Relative, Caregiver)?
Name:
Date:
Name:
Date:
Signature:
Date:
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.