Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname (Preferred Name):
Date of Birth:
Gender:
Address:
City:
State:
Zip:
Marital Status:
Spouse's Name:
Children (names and ages):
Occupation:
Employer:
Work Phone:
Home Phone:
Cell Phone:
Email:
How would you like to receive Appointment Reminders?

Special hobbies, sports, or interests:
Musical instruments played:
Physician:
Physician Phone:
Dentist Name:
Dentist Phone:
How did you hear about this office?
Whom may we thank for referring you?

Emergency Contact Information

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

Dental Insurance Information

In order to assist you in determining and receiving your orthodontic insurance benefit, please complete the following information:

Do you have dental insurance coverage?
Does the dental insurance have orthodontic coverage?
Insurance Carrier #1:
Insurance ID #:
Policy/Group #:
Insurance Carrier Phone:
Effective date of coverage:
Maximum amount of Orthodontic coverage:
Name of insured:
Relationship to Patient:
Birthdate:
Social Security #:
Insured's address:
City:
State:
Zip:
Employer name:
Work Phone:
Employer's address:
City:
State:
Zip:

Do you have any other dental insurance coverage?
Does the dental insurance have orthodontic coverage?
Insurance Carrier #2:
Insurance ID #:
Policy/Group #:
Insurance Carrier Phone:
Effective date of coverage:
Maximum amount of Orthodontic coverage:
Name of insured:
Relationship to Patient:
Birthdate:
Social Security #:
Insured's address:
City:
State:
Zip:
Employer name:
Work Phone:
Employer's address:
City:
State:
Zip:

Dental History

Date of most recent dental examination:

* Are you presently in any dental pain?
* Have you ever experienced an unfavorable reaction to dentistry?
* Have you ever knocked out or chipped any teeth?
* Have you been informed of extra or missing teeth?
* Is any part of your mouth sensitive to temperature or pressure?
* Do you brush your teeth daily?
* Do you floss regularly?
* Do your gums bleed when you brush?
* Do you predominantly breathe through your mouth?
* Do you require any pre-medication for dental procedures?
* Do you smoke or use tobacco products in any form?
* Do you have any speech problems or receive speech therapy?
* Have you ever had any pain / tenderness in your jaw (TMJ / TMD)?
* Are you aware of any jaw clicking or popping?
* Do you clench or grind your teeth?
* Have you ever experienced chronic ringing in your ears?
* Do you have "tension" headaches?
* Do you have any difficulty chewing or swallowing food?
* Does your bite feel uncomfortable?
* Are you aware that some appointments will be during work hours?

What is your primary concern with your teeth?
Have you previously had orthodontic treatment or consulted an orthodontist?
Are you aware of any dental work that needs to be completed prior to orthodontic treatment?
Have there been any injuries to your face, mouth, teeth or chin? If yes, please explain:
Have any teeth been removed by extraction? If yes, please explain:
Has anyone else in your family received orthodontic treatment? If yes, how did they feel about the results?

Medical History

Have you ever had any of the following diseases or medical conditions?
Abnormal Bleeding / Blood disorders
Anemia
Arthritis
Asthma or Hayfever
Bone disorders
Depression/Mental illness
Diabetes
Dizziness
Epilepsy
Gastrointestinal disorders
Heart problems / Congenital heart defect
Heart murmur
Hepatitis / Liver problems
Herpes
High blood pressure
HIV+ or AIDS
Kidney problems
Pneumonia / Lung disorder
Radiation / Chemotherapy
Rheumatic fever
Tonsils or adenoids removed
Total joint repleacement
Tuberculosis
Tumor or cancer
Do you have any other medical conditions not described above? If yes, please explain:

FEMALE PATIENTS:
Are you pregnant? Week #?
Are you taking birth control pills?
Are you anticipating becoming pregnant?

Do you have allergic reactions to any of the following?
Latex
Nickel
Dental anesthetics
Aspirin
Plastics

Airway / Sleep Habits

Please list any other medications or substances (e.g. penicillin, erythromycin, codeine, etc) to which you have had an allergic reaction:
Please list all medications that you are currently taking:
Are you currently under the care of a physician? If yes, please explain:
Please explain any medical problems that you have had in the past:

Patient Photo Release

The above named patient of "Dexter Orthodontics" hereby represents and warrants that they have the full legal right, power and authority to grant this agreement and hereby irrevocably consent the non-exclusive, irrevocable right, license, privilege and authority to "still" and/or "video" photograph the patient's image for the purpose, but not limited to, of company educational and promotional purposes throughout the world on any medium or forum, whether now known or hereinafter created.

This includes any photography taken before, during and after the patient's treatment.

Methods of advertising includes, but is not limited to, internal office posting, newspaper/magazine/billboard advertisements, promotional/educational materials and internet website.

The "still" or "video" images of the patient shall not be distributed or exploited separately or independently of "Dexter Orthodontics"


Patient Acknowledgement and Consent

Effective April 14, 2003, the new federal law known as the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") requires that this office comply with certain rules regarding the maintenance of the privacy of your information that we have collected and will collect in the future.

To comply with one of HIPAA’s requirements, we are giving you a copy of our Notice of Privacy Practices. This notice of Privacy Practices contains the information that HIPAA requires us to disclose regarding our privacy practices. Existing Michigan Law requires (in addition to our attempt to obtain your written acknowledgment, discussed above) us to first obtain your written consent prior to disclosing any of your information except for our disclosures in connection with: a defense to a claim challenging our professional competence; a review entity’s functions; a claim for payment of fees; a third party payer’s examination of our records; a court order as part of a criminal investigation; an identification of a dead body; a licensure investigation; or a child abuse/neglect investigation. From time to time it may be necessary for us to make disclosures of your information in connection with your treatment. For example, we make a referral to or consult with another dentist or health care professional, provide a specimen to a laboratory for testing or otherwise make disclosures of your information in connection with providing or coordinating your treatment.


We will only discuss your treatment with parents / legal guardians / the person financially responsible for your treatment and/or referring Doctors and Dentists for the furtherment of your treatment.