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:
Single
Married
Divorced
Separated
Widowed
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?
No
Yes
(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)?
Yes
No
Have there been any injuries to the face, mouth or teeth?
Yes
No
When?
Do you grind your teeth?
Yes
No
While Asleep
During the day
Do you suffer from frequent headaches, jaw aches (TMJ) or facial pain?
Yes
No
If so, when does it hurt?
How often does it occur?
Daily
Weekly
Monthly
Only on Occasion
Other
If Other:
Have you received treatment for this condition?
Yes
No
Are you still undergoing treatment?
Yes
No
By Whom?
Have you previously had an orthodontic consultation or orthodontic treatment?
Yes
No
If yes, when and by whom?
Are you a mouth breather?
Yes
No
While awake?
While asleep?
Do you have sleep disordered breathing, sleep apnea, or snoring?
Yes
No
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.
AIDS/HIV positive
Allergies to anesthetics
Allergies to latex
Allergies to medicines/drugs
Allergies to nickel/metals
Anemia
Arthritis
Asthma
Cancer
Chronic headaches
Circulatory problems
Diabetes
Excessive bleeding
Heart problems
Hepatitis
High blood pressure
Low blood pressure
Nervous problems
Osteoporosis
Psychiatric care
Radiation treatments
Rheumatic fever
Rheumatoid arthritis
Scarlet fever
Sinus problems
Stroke
Thyroid
Tonsilitis
Tuberculosis
Ulcer
Other:
Are you presently taking or have ever taken any medications for cancer or for osteoporosis?
Yes
No
If yes, please list drugs and dates:
Are you required to premedicate prior to dental visits?
Yes
No
Are you pregnant?
Yes
No
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.