Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Age:
Gender:
Address:
City:
State:
Zip:
Main Phone:
Email:
Parent Email:
2nd/Cell Phone:
Hobbies, Sports, Interests:
School (Type NA if adult):

Family Smile Plan Information

Family members currently in orthodontic treatment in our office?
Family Member Name:
Birthdate:
Gender:
Has had treatment:
Family Member Name:
Birthdate:
Gender:
Has had treatment:
Family Member Name:
Birthdate:
Gender:
Has had treatment:
Family Member Name:
Birthdate:
Gender:
Has had treatment:
Whom may we thank for referring you? Please list all referrers.
What is the patient's main orthodontic concern?

Financial Party Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Social Security Number:
Address:
City:
State:
Zip:
Main Phone:
Email:
Dental Ins. Co.:
Employed by:
Group:
Work Phone:

First Name:
Middle Initial:
Last Name:
Birthdate:
Social Security Number:
Address:
City:
State:
Zip:
Main Phone:
Email:
Dental Ins. Co.:
Employed by:
Group:
Work Phone:

Dental History

Current Family Dentist:
Seen in last 12 months?

DO YOU HAVE OR HAVE YOU EVER HAD, ANY OF THE FOLLOWING
Clenching or grinding of teeth?
Clicking, grating, pain in ear or jaw joint?
Complications from extractions?
Complication from gum treatment?
Difficulty in opening mouth?
Hyperactive ADHD?
Mouth breathing?
Oral habits (finger, nail, cheek biting, thumb sucking)?
Received a severe blow to head or chin?
Sleep issues?
TMJ or bite treatment?
Tonsils/Adenoids removed?
Do you feel you need treatment for any of these problems?
Would you be willing to engage in invasive elective oral surgery to obtain 'The ideal orthodontic result?'?

Medical History

Physician Name:
Seen in last 12 months?
Medical Ins. Co.:
DO YOU HAVE OR HAVE YOU EVER HAD, ANY OF THE FOLLOWING
Allergy to anesthetics?
Allergy to drugs?
Allergy to latex?
Allergy to metals?
Anemia, Blood Problems, or Blood Transfusions?
Arthritis or Osteoporosis?
Diabetes?
Excessive bleeding from cut or extraction?
HIV or ARC?
Hypertension/High Blood Pressure?
Other allergies or Asthma?
Liver problems or Hepatitis?
Malignancies?
Radiation Treatment?
Pregnant?
If yes, what month?:
DO YOU NEED TO BE PREMEDICATED FOR ANY AILMENTS?
List any medications currently being taken by the patient:
Health Information: I certify that this information is correct.

Insurance: To avoid misunderstanding regarding dental insurance, we wish the persons responsible to know that all professional services rendered are charged directly to them and that they are personally responsible for payment or fees. We will prepare necessary forms or reports to help the persons responsible to obtain benefits from insurance companies for receipt of full (or partial) payment of bill. We do not render our services on the basis that insurance companies will pay all our fees. Each fee is individual for the individual patient. All information contained on this form will remain confidential.

Photo Statement

For quality control purposes, we regularly photograph patients before, during and after treatment. I give permission to use these photos with commonly accepted disguise in educational, treatment and social media applications.
Patient/Parent or Guardian's Name:

HIPAA: ACKNOWLEDGMENT OF PRIVACY POLICY

This form is optional under the new patient privacy regulations recently issued by the United States Department of Health and Human Services. We have elected to use this form. Prior to commencing your orthodontic treatment, you should review, sign and date this form.

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 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 is available upon request.

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.

Insurance Protocol

We are committed to providing you with the best possible care, and are pleased to discuss our professional fees with you at any time. Your clear understanding of our Insurance Protocol is important to our professional relationship.

We must emphasize that our relationship is with you, not your insurance company. It is your responsibility to provide us with any and all changes that may occur regarding your insurance information..

Your insurance is a contract between you, your employer, and the insurance company.

We will process your insurance claims as a courtesy to you with the information you provide us. This will serve as signature on file for the submission of all insurance claims and assignment of benefit to the above named office.

Many services that are delivered in our practice (i.e.; cosmetic appliances) are not necessarily included in your insurance benefits. Therefore any difference in fees will be your responsibility.

It is your responsibility to make sure payments are made in a timely manner.

Please make sure our office is aware of any changes in your insurance coverage or carrier.

If for any reason your insurance does not pay, it will be necessary for us to bill you.

Any insurance account over 6 months past due will automatically be billed to you.

Thank you for understanding our Insurance Protocol. If you have any questions about the above information, please ask us. We are here to help you.

  1. I have read the above information. I understand and agree that I am responsible for the payment of all professional services rendered.
  2. I authorize any and all payment from my insurance company directly to Orthodontic Professionals, P.C.
  3. I authorize the release of any medical information necessary to process your insurance claims.
Patient/Parent or Guardian's Name: