New Patient Form

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone*

Please enter a valid phone number.

Birthdate*

Date

Marital Status*

Sex*

Email

example@example.com

Parent/Guardian's Name (if patient is a minor)

Name and ages of siblings (if patient is a minor)

Whom may we thank for referring you to your office?

Sports/Hobbies/Musical Instruments?

School/Occupation

Current Grade

Nickname

Same as above?*

YesNo

Name*

First NameLast Name

Relationship to Patient*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you been at this address longer than 3 years?*

YesNo

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Work Phone

Please enter a valid phone number.

Cell Phone

Please enter a valid phone number.

Social Security #

Employer

Occupation

Number of Years Employed

Is there an additional responsible party for this account?*

YesNo

Relationship to Patient

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you been at this address longer than 3 years?

YesNo

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Work Phone

Please enter a valid phone number.

Cell Phone

Please enter a valid phone number.

Social Security #

Employer

Occupation

Number of Years Employed

Insured's Name

Insured's Birthdate

Date

Insured's Employer

Social Security #

Insurance Company

Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Group Number

Subscriber/Employee ID #

Phone Number

Please enter a valid phone number.

Do you have dual coverage?*

YesNo

Insured's Name

Insured's Birthdate

Date

Insured's Employer

Social Security #

Insurance Company

Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Group Number

Subscriber/Employee ID #

Phone Number

Please enter a valid phone number.

Name of nearest relative not living with you:*

Relationship*

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please describe the main concerns that you would like our orthodontic team to address:*

Has the patient ever been evaluated for or had orthodontic treatment before?*

YesNo

Have there been any injuries to the face, mouth, teeth, or chin?*

YesNo

How does the patient feel about wearing an orthodontic appliance(s)?

Have the adenoids or tonsils been removed?*

YesNo

Has the patient been informed of any missing or extra permanent teeth?*

YesNo

Has the patient ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?*

YesNo

Does the patient brush their teeth daily?*

YesNo

Does the patient floss their teeth daily?*

YesNo

Patient's Dentist*

Phone

Please enter a valid phone number.

Date of Last Visit

Date

Patient's Physician*

Phone

Please enter a valid phone number.

Is the patient currently under the care of a physician?*

YesNo

If the patient is a minor, has puberty begun?*

YesNo

Please describe the patient's current physical health?*

GoodFairPoor

Do you take or have you taken osteoporosis medication?*

YesNo

Please list all drugs the patient is currently taking:*

Please list all allergies (drugs, foods, etc.):*

Has the patient ever had any of the following medical problems?*

	Yes	No
Abnormal Bleeding
ADD/ADHD
Sleep Apnea
Allergy to Latex/Metals
Allergy to Plastic
Any Hospital Stays
Any Operations
Asthma
Cancer
Congenital Heart Defect
Convulsions/Epilepsy
Diabetes
Handicaps/Disabilities
Hearing Impairment
Heart Murmur
Hemophilia
Hepatitis
HIV+/AIDS
Kidney/Liver Problems
Psychological Counseling
Rheumatic/Scarlet Fever
Tuberculosis (TB)

Please describe any other medical problems the patient has encountered:

Does/Has the patient have/had any of the following habits?*

	Yes	No
Chew/Smoke Tobacco
Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breather
Nail Biting
Nursing Bottle Habits
Speech Problems
Thumb/Finger Sucking
Tongue Thrust

Effective April 14, 2003, the federal law known as the Health Insurance Portability and Accountability Act of 1996 (“HIPPA”) requires that this office comply with 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 HIPPA’s requirements, we are giving you a copy of our Notice of Privacy Practices. This Notice of Privacy Practice contains the information that HIPPA requires us to disclose regarding our privacy practices.

Existing law requires (in addition to our attempt to obtain your written acknowledgment, discussed above) us to first obtain your written consent prior to disclose any of your information except for our 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.

For time to time it may be necessary for us to make disclosures of your information in connection with your treatment. For example, we may make a referral to or with another dentist or other 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.

Please sign this form below to consent to our disclosure of your information that we deem necessary in order to provide you with proper treatment.

I acknowledge the HIPPA Agreement above.I consent to your disclosure of my information, which you deem necessary in connection with my treatment. I understand that such disclosures may not be of the type listed above.

I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in the patient's medical status. I authorize the dental staff to perform the necessary dental services I/My Child may need.This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use services of one or more credit reporting agencies.If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.By signing this Agreement electronically, you agree your electronic signature is the legal equivalent of your manual signature of this Agreement.

Signature

Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

Please review your form to make sure it is complete and press the Submit button when you are done.

New Patient Form

Person Responsible for Account

Dental Insurance Information

Emergency Information

Medical History

HIPAA Acknowledgement