Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Gender:
Email:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Preferred Contact
Patient's Dentist:
Dentist's Practice Name:
Dentist's Phone:
Last Dental Visit:
School:
or Profession/Employer:
Whom may we thank for referring you to our practice?
Reason for seeking Orthodontic treatment:
Have you or anyone in the family had Orthodontics in the past? If so, when?
By whom?
What was treated Orthodontically?

Family Information

First Name:
Last Name:
Marital Status:
Relationship to patient:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Preferred Contact
Email:
Email 2:
Employer:
Occupation:
Responsible Party #2
First Name:
Last Name:
Marital Status:
Relationship to patient:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Preferred Contact
Email:
Email 2:
Employer:
Occupation:
Names and ages of children in the family:

Emergency Information

Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:

Insurance Information

Do you have dental insurance?
Does it cover orthodontics?
Primary Insurance
Insurance Company Name:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Policy Holder's Name:
Policy Holder's Birthdate:
Policy Holder's Employer:
Subscriber ID:
Group Number:
Social Security #:
Do you have secondary insurance? If so, please fill in information below.
Secondary Insurance
Insurance Company Name:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Policy Holder's Name:
Policy Holder's Birthdate:
Policy Holder's Employer:
Subscriber ID:
Group Number:
Social Security #:

Medical History

Do you have or have you ever been treated for any of the following? Cannot be blank.
Sleep Apnea?
AIDS?
Prolonged Bleeding?
Asthma?
HIV?
Fainting or Dizziness?
Heart disease (incl. high BP) or Stroke?
Tuberculosis?
Nervous Disorders?
ADD/ADHD?
Anemia?
Liver Disease or Hepatitis?
Rheumatic Fever?
Epilepsy?
Pregnancy?
If pregnancy, did you breast feed?
Bone Disorders?
Kidney Disease?
Cancer or Tumor?
Glaucoma?
Pneumonia?
Eating Disorders, Bulimia, Anorexia?
Diabetes?
Endocrine Problems?
Frequent Colds?
Frequent Sore Throats?
Frequent Ear Infections?
Have there been any injuries to face, mouth, or teeth?
Any history of thumb, digit, or pen sucking?
Any history of nail, lip, cheek, or tongue biting?
Any history of clenching or grinding teeth?
Any history of speech problems or speech therapy?
Have tonsils and/or adenoids been removed? If so, when?
Please list any medications currently being taken by the patient (include non-prescription):
Please list any drug allergies or sensitivities:
Are there any other dental/medical issues or details that you think we should be aware of?

Photo and Records Release

I, the undersigned, do hereby request and give my permission to Dr. Rebecca Bockow, DDS, MS and Inspired Orthodontics to provide other health care providers and insurance companies any and all information with respect to my dental care. Such records may include medical care and treatment, illness or injury, dental history, medical history, consultation, prescriptions, xrays, models and copies of all dental and medical records.

I, the undersigned, do hereby relinquish any and all rights to photographs, portraits, prints, or other photographic reproductions captured with still, motion picture, video, digital or other cameras for use by Rebecca Bockow, DDS, MS, and Inspired Orthodontics. Unless images are used to communicate with another care provider, no names, birthdates or identifiable information will be linked to any image.

E-Signature:

Acknowledgment of Receipt of Statement of Privacy Practices

I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Rebecca Bockow, DDS, PLLC. The Statement of Privacy Practices describes that types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility and on the office website.

Rebecca Bockow, DDS, PLLC reserved the right to change the privacy practices currently describes in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

Additional Disclosures Authorization

In addition to the allowable disclosure described in the Statement of Privacy Practices. I hereby specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified below. (I understand that the default answer is “NO”. Without indicating “YES” in answer to each individual question, personal protected information (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.)

Spouse only:
Any member of the immediate family: (Spouse, Children, Children's Spouses)
Any member of my extended family: (Parents, Grandchildren)
Other:
Patient's E-Signature:
Patient's Personal Representative's E-Signature: