NewPatientForms

New Patient Forms
Patient Information
Full Name:*

First NameLast Name
Nickname:
Birthdate:*

MonthDayYear
Date
Gender:
Address*

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone:*
Cell phone provider:*
Email
example@example.com
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
What helped you to decide on Oldham Orthodontics?*
Dentist, Friend, Family, Social Media, Google, Website, other
Financial Party/Insurance Information
Name*

First NameLast Name
Relationship to patient:
Cell Phone:*
Email:
example@example.com
Address

Address (if different from patient)

Street Address Line 2

CityState

Zip
Dental Insurance company:
Subscriber Name:
Employer:
Subscriber Birthdate:

MonthDayYear
Date
Member ID or SS#:
Group #:
Subscriber Relationship to patient:

MEDIA RELEASE
I hereby GRANT Dr. Cody Oldham permission to post/display a photograph/image of myself and/or my child(ren) in his office or on Oldham Orthodontics’ website and/or social media.
AGREEDISAGREE
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
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 our office staff.
AGREE
I hereby acknowledge that I have reviewed a copy of this privacy notice. (PDF available on Patient Forms section of www.OldhamOrtho.com or at the front desk)
AGREE
AUTHORIZATION FOR RELEASE OF ORTHODONTIC RECORDS AND XRAYS
I hereby authorize Oldham Orthodontics to release my and/or my child's orthodontic records, including x-rays, to my and/or my child's general dentist and/or other dental specialist/health care provider as applicable.
AGREE
CERTIFICATION
I certify that I am the authorized representative for the patient.I certify that I am the patient.
Relation to patient if not self
I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION. I grant authority to the Doctor and Staff to perform all procedures and treatments in my best interest. I authorize the Orthodontist to share treatment information with collaborating dentists and surgeons when appropriate. I authorize the Orthodontist to submit treatment information pertinent to this patient to the Insurance Company for billing purposes only.
Signature

Clear
Should be Empty:

New Patient Forms

Patient Information

Financial Party/Insurance Information

Health History

Dental History

Medical History

Patients Under 18

MEDIA RELEASE

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

AUTHORIZATION FOR RELEASE OF ORTHODONTIC RECORDS AND XRAYS

CERTIFICATION