Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Social Security #:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
School / Grade:
Is patient interested in treatment?
List name & birthdate of any siblings:

Parent Information

First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Social Security Number:
Birthdate:
Relationship to Patient:
Employer / Occupation:
Length of Employment:
Work Phone:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Social Security Number:
Birthdate:
Relationship to Patient:
Employer / Occupation:
Length of Employment:
Work Phone:

Insurance

Do you have insurance that covers orthodontics?
If so, please name the Primary Insurance Company:
Do you have Secondary insurance?
If so, please name the Insurance Company:
Policy Holder's Name:
Policy Holder's Birthdate:
Policy Holder's Policy ID or SS#:

Dental History

Dentist Name:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when?
What is the patient's main orthodontic concern?
Please select YES or No for the Following Questions - Do Not Leave Blank
Speech problems/therapy?
Grind or clench teeth?
Injury to face, jaw, teeth or mouth?
Discomfort from teeth or gums?
Pain, tenderness or noise in either jaw?
- Frequent headaches?
Oral habits (thumb/finger sucking, lip/nail biting)?
Neck/shoulder pain?
Frequent sore throats?
Brush teeth daily?
Floss teeth daily?
Fluoride treatments?
Mouth breathing?
Snores during sleep?
Requires premedication?
Any missing or extra permanent teeth?
Apprehensive about dental care?
Frequently Chew Gum?
If any of the above dental history questions were answered 'Yes' , please explain:
List any additional dental diagnoses we need to be aware of:

Medical History

Physician Name:
Date of Last Physical:
Patient Health:
Address:
City:
State:
Zip:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Liver disease, jaundice, or hepatitis?
Kidney disease?
Heart attack or stroke?
Heart disease?
Congenital heart defect?
Heart murmur?
Hemophilia?
High blood pressure or hypertension?
Prolonged bleeding or transfusion?
Anemia?
HIV or AIDS?
Hepatitis?
Tonsils or Adenoids Removed?
Growth problems?
Thyroid or endocrine problems?
Hormone therapy?
Latex/Metal Allergy?
Nervous disorders?
Bone disorders or loss?
Diabetes?
Seizures/Epilepsy?
Handicaps/Disabilities?
Asthma?
Arthritis?
Treated for emotional problems?
Ever been hospitalized?
If any of the above medical questions were answered 'Yes' , please explain:
List any additional medical diagnoses we need to be aware of:

Emergency Information

Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
Signature of Patient (of Guardian if under 18)


Acknowledge of Receipt of Notice of Privacy Practices

I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used for the following:

  • Conduct, plan and direct my treatment and follow-up among multiple healthcare providers who may be involved in the treatment directly or indirectly.
  • Obtain payment from third party payers and confirm coverage.
  • Conduct normal healthcare operations such as quality assessments and physician certifications.
  • Confirm appointments using email, text, voicemail, postcards, or letters.
  • Disclose health information to a family member, friend, or caregiver to the extent necessary to help you with your healthcare.

I acknowledge that I have read and/or received the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry our treatment, payment, or healthcare information. I also understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Signature of Patient (of Guardian if under 18)