Confidential Patient Information
First Name:
MI:
Last Name:
Preferred Name:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Cell Phone:
Home Phone:
Work Phone:
Email:
Preferred Method of Contact
Phone
Text
Email
Place of Employement:
Occupation:
Spouse's Name:
Preferred Phone:
Place of Employement:
Occupation:
Your hobbies/interests:
Specific concerns about your smile:
Dentist:
Family members seen by us:
Whom may we thank for referring you?
Responsible Party
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Address:
City:
State:
Zip:
Cell Phone:
Home Phone:
Email:
Preferred Method of Contact
Phone
Text
Email
Primary Insured Name:
S.S. # of Insured:
Insurance Company:
Date of Birth:
Secondary Insured Name:
S.S. # of Insured:
Insurance Company:
Date of Birth:
Dental and Medical History
Concerns
Please select 'Yes' if the patient has any of the concerns listed below. Cannot be blank.
Crowding
No
Yes
Spacing
No
Yes
Misaligned teeth
No
Yes
Overbite
No
Yes
Protrusion of teeth
No
Yes
Receded jaw
No
Yes
Prominent jaw
No
Yes
Missing teeth
No
Yes
Periodontal (gum) disease
No
Yes
Irregular teeth (shape, color)
No
Yes
TMJ pain/disorder
No
Yes
Dental History
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Injury to teeth, jaw, or face?
No
Yes
Jaw or face pain?
No
Yes
Clicking, popping, or locking of jaw?
No
Yes
Clenches jaw/grinds teeth?
No
Yes
Thumb/finger habit?
No
Yes
Chews on object (nails, pens, other)?
No
Yes
Tongue thrust?
No
Yes
Mouth breathing?
No
Yes
Have you had a previous orthodontic evaluation?
No
Yes
Medical History
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
ADD/ADHD?
No
Yes
Asthma?
No
Yes
Autoimmune disorder?
No
Yes
Blood disease?
No
Yes
High blood pressure?
No
Yes
Bone disease/arthritis?
No
Yes
Diabetes?
No
Yes
Delayed growth?
No
Yes
Eating disorder?
No
Yes
Emotional concerns?
No
Yes
Endocrine disorder?
No
Yes
Epilepsy/Seizures/Fainting spells?
No
Yes
HIV+/AIDS?
No
Yes
Heart disease?
No
Yes
Heart murmur?
No
Yes
Hepatitis?
No
Yes
Hearing impairment?
No
Yes
Pregnant/possibly pregnant?
No
Yes
Speech impairment?
No
Yes
Tonsils/Adenoids removed?
No
Yes
Please list any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Latex?
No
Yes
Nickel?
No
Yes
Plastic?
No
Yes
Please list any other drug allergies or sensitivities that the patient may have:
Please provide any additional information you feel is important:
Emergency Contact Information
Name:
Phone:
Consent to Notice of Privacy Practices
I understand that I have certain rights to privacy regarding my protected health information. These rights have been established under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize Davison Orthodontics to use and disclose my protected health information to carry out the following: treatment, including direct or indirect treatment, by other healthcare professionals involved in my care; obtaining payment from third party payers such as my insurance company; healthcare operations of my provider.
I have been given the right to review and secure a copy of your
Notice of Privacy Practices
, which provides a description of the uses and disclosure of my protected health information. I understand that you reserve the right to revise the terms of this notice and that I may contact you to request an updated copy of this notice.
I understand that I have the right to request certain restrictions on the manner in which my protected health information is used to carry out treatment, payment, and healthcare operations. I understand that you are not required to consent to these restrictions.
I understand that I may revoke this consent, at any time, in writing. I understand that should I revoke this consent, any disclosure prior to that date is not affected.
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Patient E-Signature:
Date: