• Health History Form and Privacy Practices Acknowledgement - Adult

  • Thank you for scheduling an appointment at Montgomery Orthodontics. Prior to your first appointment, please complete Sections 1 - 9 of this form.

    The information you provide will be sent to our office with secure encryption. Our office complies with HIPAA Privacy requirements (see Section 7 of this form). Completion of this form prior to your appointment will save you time during your visit to our office and will allow us to verify your insurance coverage.

    You can expect that it will take approximately 10 minutes to complete this form. If you have any questions, please call our office at (609) 688-1611.

    We look forward to seeing you.

  • Section 1: Patient Information

  • 4. Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Section 2: Additional Information About You

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • 6. Preferred Phone Number*

  • Section 3: Primary Orthodontic Insurance Information

  • 1. Do you have primary orthodontic insurance coverage?*
  • 3. Subscriber's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 7. Check any that apply:*
  • 8. Plan Type*
  • Format: (000) 000-0000.

  • Section 4: Secondary Orthodontic Insurance Information

  • 1. Do you have secondary orthodontic insurance coverage?*
  • 3. Subscriber's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 7. Check any that apply:*
  • 8. Plan Type*
  • Format: (000) 000-0000.

  • Section 5: Patient Medical History

  • 1. Do you have a Physician?*
  • 3. Approximate date of your last visit physical exam*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • 6. Are you currently taking any medication*
  • 8. Are you allergic to latex?*
  • 9. Are you allergic to any medication*
  • 11. Are you allergic to metals?*
  • 13. Do you have a history of any medical illness?*
  • 15. Have you had any surgeries?*
  • 17. Have you ever been involved in a serious accident?*
  • 19. Please check any of the following that applies to you. If none of these apply to you, please check "NONE OF THE ABOVE"*
  • 20. Are you pregnant?*
  • 21. How would you describe your current health (good, fair, or poor)?*

  • Section 6: Patient Dental History

  • 1. Do you have a dentist?*
  • Format: (000) 000-0000.
  • 5. Approximate date of your last visit to the Dentist*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 6. Approximate date of your last Dental X-Rays*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 7. Have you had a panoramic x-ray taken?*
  • 8. Approximate date of last panoramic x-ray*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 10. Have you ever had or been evaluated for orthodontic treatment?*
  • 12. Do you like your smile?*
  • 14. What are you most interested in learning more about?*
  • 15. Do you have dental implants?*
  • 16. Do you have any unfinished or planned dental work?*
  • 18. Have you experienced trauma to their teeth or jaw?*
  • 20. Please indicate any temporomandibular joint problems that apply to you. If none of these apply to you, please check "NONE OF THE ABOVE"*
  • 21. Have you ever had any temporomandibular joint therapy?*
  • 22. Have you ever had jaw surgery?*
  • 23. Do you wear a night guard?*
  • 24. Have you ever had speech therapy and/or myofunctional therapy?*
  • 26. Have you had any of your wisdom teeth removed?*
  • 27. Do your gums ever bleed?*
  • 28. Have you been treated for periodontal disease?*
  • 29. Do you require antibiotics before dental procedures?*
  • 30. Do you require a mouth guard?*
  • 31. Do you brush your teeth daily?*
  • 32. Do you floss your teeth daily?*
  • 33. Describe your current dental health (good, fair, or poor)?*
  • 34. Please check anything below that applies to you. If none of these apply to you, please check "NONE OF THE ABOVE"*
  • 36. How would you describe your expected level of cooperation with orthodontic treatment*

  • Section 7: HIPAA Notice of Privacy Practices

  • Please review the following Notice of Privacy Practices

  • Section 8: Authorization and Acknowledgement

  • By clicking "Submit",

    • I understand that the information I have given is correct to the best of my knowledge, and is accessed only via a secure, encrypted interface.
    • I understand that it is my responsibility to inform Montgomery Orthodontics of any changes to the information I provided on this form.
    • I consent to share dental records from Montgomery Orthodontics with my child's dentist and/or dental professionals for purposes of Patient care.
    • I consent to receive appointment reminders via text message and/or email. I may opt-out of this at any time by notifying Montgomery Orthodontics.
    • I understand that I am responsible for full payment of services rendered and also responsible for paying any co-payments and deductibles that my insurance does not cover. I am responsible for notifying Montgomery Orthodontics of any changes in my insurance coverage.
    • I understand and have read the Notice of Privacy Practices provided in Section 8 of this form and that I may request a copy of such policy at any time.
  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Section 9: Submit the form

  • Should be Empty: