Confidential Patient Information

Patient's First Name:
Middle Initial:
Last Name:
Nickname (Preferred Name):
Date of Birth:
Gender:
Preferred Pronouns:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:

Physician:
Physician Phone:
Dentist Name:
Dentist Phone:

Patient's School:
Grade:
Special hobbies, sports, or interests:
Musical instruments played:
How did you hear about this office?
Whom may we thank for referring you?

Guardian Information

Guardian #1
First Name:
Last Name:
Relationship to Patient:
Address:
City:
State:
Zip:
Occupation:
Email:
Home Phone:
Cell Phone:
How would you like to receive Appointment Reminders?

Guardian #2
First Name:
Last Name:
Relationship to Patient:
Address:
City:
State:
Zip:
Occupation:
Email:
Home Phone:
Cell Phone:
How would you like to receive Appointment Reminders?

Guardian #3
First Name:
Last Name:
Relationship to Patient:
Address:
City:
State:
Zip:
Occupation:
Email:
Home Phone:
Cell Phone:
How would you like to receive Appointment Reminders?

Marital Status of Parents:
If divorced, who will be financially responsible?
Siblings (names and birthdates):

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

* Is your child presently in any dental pain?
* Has your child ever experienced an unfavorable reaction to dentistry?
* Has your child ever knocked out or chipped any teeth?
* Has your child been informed of extra or missing teeth?
* Is any part of your child's mouth sensitive to temperature or pressure?
* Does your child brush their teeth daily?
* Does your child floss regularly?
* Do your child's gums bleed when they brush?
* Does your child predominantly breathe through their mouth?
* Does your child require any pre-medication for dental procedures?
* Does your child have any kind of finger / thumb or tongue habit?
* Does your child have any speech problems or receive speech therapy?
* Has your child ever had any pain / tenderness in their jaw (TMJ / TMD)?
* Is your child aware of any jaw clicking or popping?
* Has your child been told that they clench or grind their teeth?
* Has your child ever experienced chronic ringing in their ears?
* Does your child have "tension" headaches?
* Does your child have any difficulty chewing or swallowing food?
* Does your child's bite feel uncomfortable?

Date of last dental examination:
Indicate the patient's feelings / attitude toward treatment:
What is the patient's primary concern with their teeth?
Has an orthodontist been previously consulted?
Are you aware of any dental work that needs to be completed prior to orthodontic treatment?
Have there been any injuries to your child's 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 the patient 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
Does the patient have any other medical conditions not described above? If yes, please explain:

Airway / Sleep Habits

Is your child allergic to any of the following?
Latex
Nickel
Dental anesthetics
Aspirin
Plastics
Please list any other medications or substances (e.g. penicillin, erythromycin, codeine, etc) to which your child has had an allergic reaction:
Has your child been diagnosed with any emotional disorders, including ADD / ADHD? If yes, please list any medications:
Please list all medications that your child is currently taking:
Is your child currently under the care of a physician? If yes, please explain:
Please explain any medical problems that your child has had in the past:

* Does your child follow directions well?
* Does your child have a learning disability or need extra help with instructions?
* Is your child sensitive or self-concious?
* Are you aware that some appointments will be during school / work hours?

Maturation

If patient is a girl, has menstruation begun?
If yes, what year did it begin?
If patient is a boy, has their voice changed?
If yes, when did it start?
If patient is a boy, have they started growing facial hair?
How much grown in past year (inches)?
Other indicators of maturation?

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

Signature of parent / legal guardian:
Relationship to Patient: