Welcome to Our Office

Thank you for making an orthodontic evaluation appointment with us. Our practice is very fortunate to have three board certified orthodontists. Dr. Peter Wendell has had the privilege of creating beautiful smiles for our community since 1984 and served as an associate clinical professor of orthodontics at the Medical College of Virginia for 32 years.

Our outstanding husband and wife team, Doctors Matt and Patti Eppright, excelled in their studies at the nationally ranked programs at the Medical College of Virginia and the University of Rochester Institute for Oral Health. Before joining our team, they practiced orthodontics in eastern Pennsylvania for several years.

At the initial examination visit, the patient's orthodontic treatment will be discussed and an estimate for the cost of this therapy will be given. Please feel free to express any concerns you may have during this initial appointment.

If unable to keep this appointment, please call our office and we will be happy to reschedule the examination for you.

Welcome to our office! We look forward to meeting you.

Sincerely,

The Team at Williamsburg Orthodontics

Confidential Patient Information

Title:
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Social Security #:
Email:
Marital Status:
Employer/School:

Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?

Financial Party Information

Title:
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Marital Status:
Email:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Social Security Number:
Employer:

Dental Insurance Information

Do you have dental coverage?
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:

Do you have dual dental coverage?
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:

Dental History

Dentist Name:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when?
What is the patient's main orthodontic concern?

Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Apprehensive about dental care?
Clench or grind teeth?
Discomfort from teeth or gums?
Frequent headaches?
Injury to face, jaw, teeth, or mouth?
Missing or extra permanent teeth?
Mouth breathing?
Neck or shoulder pain?
Oral habits (thumb or finger sucking, lip or nail biting)?
Pain, tenderness, or noise in either jaw?
Snores during sleep?
Requires premedication?
Speech problems or therapy?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Patient Health:
Address:
City:
State:
Zip:
Please list any medications currently being taken by the patient (include non-prescription):
Please list any other drug allergies or sensitivities that the patient may have:
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?
Anemia or blood disorder?
Anxiety/Depression?
Arthritis or joint problems?
Asthma?
Autism/Autism Spectrum?
Bisphosphonates (Fosamax, Boniva)?
Bone Disorders/Bone Loss/Artificial Joints?
Cancer?
Cancer in family history?
Diabetes?
Dyspraxia (Sensory Processing)?
Emotional problems treatment?
Endocrine problems?
Growth problems?
Handicaps or disabilities?
Heart attack or stroke?
Heart defect (congenital)?
Heart disease?
Heart murmur?
Hemophilia?
Hepatitis?
High blood pressure or hypertension?
HIV or AIDS?
Hormone therapy?
Kidney disease?
Latex or Metal Allergy?
Liver disease, jaundice, or hepatitis?
Nervous disorders?
Pneumonia?
Prolonged bleeding or transfusion?
Radiation treatment?
Rheumatic fever?
Seizures, epilepsy, or neurological disease?
Tonsils or adenoids removed?
Tuberculosis or lung disease?
If any of the above medical questions were answered 'Yes' , please explain:

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Please list the name and age of any siblings:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:

Has patient begun puberty?
If patient is a girl, has menstruation begun?
If patient is a boy, has their voice changed or have facial hair?

Privacy Notice

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your protected health information (i.e., individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:
  • To other health care providers (i.e., your general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you (i.e., to determine the results of cleanings, surgery, etc.);
  • To third party payers or spouses (i.e., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e., to determine benefits, dates of payment, etc.);
  • To certifying, licensing and accrediting bodies (i.e., the American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation;
  • Internally, to all staff members who have any role in you treatment;
  • To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling, etc;
  • To your family and close friends involved in your treatment; and/or,
  • We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke.

Under the new privacy rules, you have the right to:
  • Request restrictions on the use and disclosure of your protected health information;
  • Request confidential communication of your protected health information;
  • Inspect and obtain copies of your protected health information through asking us;
  • Amend or modify your protected health information in certain circumstances;
  • Receive an accounting of certain disclosures made by us of your protected health information; and,
  • You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our Privacy Contact Person at our office address) or the United States Secretary of Health and Human Services (which must be filed within 180 days of the violation).
We have the following duties under the privacy rules:
  • By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information;
  • To abide by the terms of our Privacy Notice that is currently in effect;
  • To advise you of our right to change the terms of this Privacy Notice and to make the new notice provisions effective for all protected health information maintained by us, and that if we do so, we will provide you with a copy of the revised Privacy Notice.
Please note that we are not obligated to:
  • Honor any request by you to restrict the use or disclosure of your protected health information;
  • Amend your protected health information if, for example, it is accurate and complete; or,
  • Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.
This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Contact Person or direct your questions to this person at our address. Thank you.

PATIENT ACKNOWLEDGMENT OF HIPAA PRIVACY ACT

I hereby acknowledge that I have been shown and reviewed a copy of this Privacy Notice.
Patient's Name:
Patient or Responsible Party Signature (if patient is a minor):
Date: