Patient Information
First Name:
Middle Initial:
Last Name:
Birthdate:
Address:
City:
State:
Zip:
Contact Number:
Email:
Social Security #:
How did you hear about us?
Responsible Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Cell Phone:
Home Phone:
Employer:
Employer Address:
Insurance Information
Insurance Company Name (Please enter N/A if you do not have one):
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Subscriber ID:
Group Number:
Birthdate:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Insurance Company Name:
Insurance Company Phone:
Subscriber ID:
Group Number:
Emergency Contact
Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Cell Phone:
Home Phone:
Medical/Dental History
Do you have a dentist?
No
Yes
Dentist Name:
Dentist Phone:
Date of last visit:
List of Prescribed drugs:
For Women:
Have you started your periods?
No
Yes
Are you using a prescribed method of birth control?
No
Yes
Are you pregnant or nursing?
No
Yes
Have you ever had any of the following:
Abnormal bleeding
No
Yes
Anemia
No
Yes
Artificial bones/joins/valves
No
Yes
Arthritis
No
Yes
Asthma
No
Yes
Blood Transfusion
No
Yes
Cancer/Chemotherapy
No
Yes
Congenital Heart Defect
No
Yes
Diabetes?
No
Yes
Difficulty Breathing
No
Yes
Drug/Alcohol Abuse
No
Yes
Emphysema
No
Yes
Epilepsy/Seizures/Fainting
No
Yes
Glaucoma
No
Yes
Heart Attack/Stroke
No
Yes
Heart Murmur
No
Yes
Hemophilia?
No
Yes
Hepatitis
No
Yes
High/Low Blood Pressure
No
Yes
HIV+/AIDS
No
Yes
Hospitalization for any reason
No
Yes
Kidney Problems
No
Yes
Mitral Valve Prolapse
No
Yes
Psyciatric Problems
No
Yes
Radiation treatment
No
Yes
Rheumatic/Scarlet Fever
No
Yes
Severe/Frequent Headaches
No
Yes
Shingles
No
Yes
Sickle Cell Disease
No
Yes
Sinus Problems
No
Yes
Tuberculosis (TB)
No
Yes
Ulcers/Colitis
No
Yes
Venereal Disease
No
Yes
Other:
Are you allergic to any of the following?
Acetaminophen
No
Yes
Aspirin
No
Yes
Codeine
No
Yes
Dental anesthetics?
No
Yes
Erythromycin
No
Yes
Ibuprofen or NSAID's
No
Yes
Latex
No
Yes
Any metal or plastics
No
Yes
Penicillin or other antibiotics?
No
Yes
Tetracycline
No
Yes
Other:
How often do you brush your teeth?
How often do you floss?
What are the main concerns that you would like the orthodontist to accomplish?
Have you ever been evaluated for orthodontic treatment?
No
Yes
Have you had any major issues with dental work?
No
Yes
Do you now or have you ever experienced pain/discomfort in your jaw join (TMJ/TMD)?
No
Yes
Do your gums ever bleed?
No
Yes
Have you ever had an injury to your mouth/teeth/chin?
No
Yes
Do you clench or grind your teeth?
No
Yes
Do you have any speech problems?
No
Yes
Do you generally breathe through your mouth?
No
Yes
Do you have any missing or extra permanent teeth?
No
Yes
Have you ever taken Fosamax or bisphosphonate
No
Yes
Do you smoke or use tobacco in any form?
No
Yes
I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.
Signature:
Date:
Acknowledgement of Notice of Privacy Practices
I have received a copy of this office's Notice of Privacy Practices.
I authorize Orthoroks Orthodontics to discuss personal treatment and finances with the following individual(s):
Signature:
Date:
Consent to Dental Photography
I authorize Dr. Richa Dutta, to take photographs, and/or videos of my face, jaws and teeth, before, during and after treatment.
I consent to allow the photographs to be used for the following:
Dental Records
Dental Research
Dental Education including lectures, seminars, demonstrations, professional publications such as journals or books
Marketing material including websites, social media, printed materials and patient education.
I further understand that if the photographs and/or videos are used, my name or other identifying information will be kept confidential.
I do not expect compensation, financial or otherwise, for the use of these photographs.
Signature:
Date:
Other Notices
To our private insurace patients
As a courtesy to you, we will be happy to submit for pre-authorization and/or payment to all insurance companies with a completed and signed insurance form
We will initially ask you for only your estimated co-insurance payment. Please understand that this is only an estimate and is based upon the accuracy of the information available to us from your insurance provider. We will also be unable to carry balances unpaid by the insurance carriers longer than 90 days after the initial submission of claims. After three months, we will require all patients to pay the balances in full and be reimbursed directly from their insurance companies. We reserve the right to pursue all delinquent accounts via a third party collection agency or attorney.
Please familiarize yourself with your dental benefits to be aware of deductibles, time restraints, yearly maximums, and your percentage of financial responsibility. We would like you to understand fully the ultimate responsibility for payment is yours. All patients are responsible for payment in full or agreed upon payment plan at the time of service.
**All patients under the age of 18 must be accompanied by a parent or legal guardian on all visits. We reserve the right to charge for broken or missed appointments without 24 hours notice. A fee of $15.00 may be assessed for failure to notify the office.
**A $35.00 service charge will be assessed for all returned checks.
ALL PATIENTS:
We require all patients over the age of 18 to provide us with their Social Security number. Though many insurance companies have unique identification numbers, they are subject to change when your insurance changes. When insurance is involved, we ask you to remember that we are extending credit to you by collecting only percentage or co-insurance payment and billing your insurance company for the balance. In addition, we ask you to remember that your name and date of birth are not always enough to uniquely identify you for your records purposes. If you prefer not to make this information available to us, we will require cash payment in full at the time of your visit.
I have read and fully understand the terms stated above.
Signature:
Date: