Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Social Security #:
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?

Financial Party Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Email:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Social Security #:

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Date of Birth:
Insurance Company:
Subscriber ID:
Group Number:
Policy Holder's Employer:
Insurance Company Address:
City:
State:
Zip:

Dental History

Dentist Name:
Check-up Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
If so, when?
What is the patients 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?
Chipped or injured permanent teeth?
Previous root canal therapy?
Bad taste or mouth odor?
Previous periodontal (gum) treatment?
Abnormal swallowing (tongue thrust)?
Teeth that irritate tongue, cheek, lip, etc?
Numerous fillings?
Jaw fractures, cysts, or mouth infections?
Frequent canker sores or cold sores?
Have wisdom teeth been removed?
Problems with food trapped between teeth?
Is all dental work completed at this time?
If any of the above dental questions were answered 'Yes', please explain:
Have you had a TMJ screening?
Do you have a history of jaw joint problems?
Have you been treated for "TMJ"?
Do you notice clicking or popping in your jaw joint?
Does your bite feel uncomfortable or unusual?
Do you experience soreness in the muscles of your face or around your ears?

Medical History

Physician Name:
Date of Last Physical:
Patient Health:
Address:
City:
State:
Zip:
List any medications currently being taken by the patient:
Allergies or drug reaction to:
Aspirin, Ibuprofen, or Tylenol?
Codeine or other narcotics?
Latex?
Local anesthetics?
Penicillin or other antibiotics?
Sulfa drugs?
Other?
Please list any other drug allergies or sensitivities that the patient may have:
Please select YES or No for the Following Questions - Do Not Leave Blank
Rheumatic Fever
Tuberculosis/Lung Disease
Pneumonia
Liver Disease
Kidney Disease
Heart Attack/Stroke
Heart Disease
Congenital Heart Defect
Heart Murmur
Hemophilia
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia
HIV/AIDS
Hepatitis
Tonsils/Adenoids Removed
Cancer
Family History of Cancer
Received Radiation Treatment
Growth Problems
Endocrine Problems
Hormone Therapy
Latex/Metal Allergy
Nervous Disorders
Bone Disorders/Bone Loss
Diabetes
Seizures/Epilepsy
Handicaps/Disabilities
Asthma
Arthritis
Treated for Emotional Problems
Ever Been Hospitalized
Take Bisphosphonates (Fosamax, Boniva)
ADHD/ADD?
Angina?
Liver disease, jaundice, or hepatitis?
Arthritis or joint problems?
Substance abuse problem (past or present)?
Smoking/Vaping Habit?
FEMALES: Are You Pregnant?
If any of the above medical questions were answered 'Yes' , please explain:

Patient Motivation For Orthodontic Treatment

Patients often request changes to their appearence and/or relief from pain or discomfort. Please help us to understand your concerns by selecting the best answers to the following questions. Be as specific as possible. If you are unsure or indifferent to a question, leave it blank.

If your teeth could be changed, how would you like them to change?

Straighten front teeth:
Straighten back teeth:
Move upper teeth:
Move lower teeth:
Eliminate spaces between teeth:
Eliminate crowding of teeth:
Make line of upper teeth more level:
Other:

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Please list the name and birthdate of any siblings:
Height:
Weight:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment:

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

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 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 payers 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; and/or,
  • 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;
  • 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 use of your privacy right with us (by submitting inquiries 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 that if we do so, we will make available to you, 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; or,
  • Provide an atmosphere that is totally free of the possibility that your protected health information may be accidentally 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. Thank you.