Health History Form, and HIPAA Privacy Practices Acknowledgement

Health History Form and Privacy Practices Acknowledgement - Child
Thank you for scheduling an appointment at Montgomery Orthodontics. Prior to your child's first appointment, please complete Sections 1 - 10 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 8 of this form). Completion of this form prior to your child's 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 - 15 minutes to complete this form. If you have any questions, please call our office at (609) 688-1611.

We look forward to seeing you and your child.
Section 1: Patient Information

Please complete the following information for your child
1. Name of Child Patient*

First NameLast Name
2. Nickname (prefer to be called this name)
3. Current Age (years)*
4. Date of Birth*

MonthDayYear
Key in the date (no dashes) or use the date picker
5. Birth Gender*
6. Gender Identity
7. School Currently Attending*
8. Current Grade*
9. Hobbies*
10. Whom may we thank for referring you to our office?
11. Other family members who are patients at our office
12. Address (where your child resides)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Section 4: Primary Orthodontic Insurance Information
1. Do you have primary orthodontic insurance coverage?*

YesNo
2. Subscriber's Name*

First NameLast Name
3. Subscriber's Date of Birth*

MonthDayYear
Key in the date (no dashes) or use the date picker
4. Dental Insurance Company*
Note, this is likely different than your Medical Insurance Company
5. Subscriber's Identification Number or Social Security Number*
6. Subscriber's Group Number*
7. Check any that apply:*

Dental benefits onlyDental and orthodontic benefits
8. Plan Type*

PPODMOOtherDon't know
9. Dental Insurance Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
10. Dental Insurance Company Phone Number*

Section 5: Secondary Orthodontic Insurance Information
1. Do you have secondary orthodontic insurance coverage?*

YesNo
2. Subscriber's Name*

First NameLast Name
3. Subscriber's Date of Birth*

MonthDayYear
Key in the date (no dashes) or use the date picker
4. Dental Insurance Company*
Note, this is likely different than your Medical Insurance Company
5. Subscriber's Identification Number or Social Security Number*
6. Subscriber's Group Number*
7. Check any that apply:*

Dental benefits onlyDental and orthodontic benefits
8. Plan Type*

PPODMOOtherDon't know
9. Dental Insurance Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
10. Dental Insurance Company Phone Number*

Health History Form and Privacy Practices Acknowledgement - Child