Adult - New Patient Forms

First Name*

Middle Initial

Last Name*

Preferred Name

Sex*

MaleFemaleOther

Marital Status*

SingleMarriedDivorcedWidowed

Date of Birth*

Date

Phone Number*

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Occupation

Employer

Hobbies and Interests

Have you had previous orthodontic treatment?*

YesNo

If yes, please describe:

I'm interested in:

BracesInvisalignBoth

What is your primary concern for your initial consultation?*

Do you have any relatives that we've seen in our office?

YesNo

If yes, please list their names:

How did you hear about our office?*

Which office location(s) is most convenient for you?*

Ward (Honolulu)KahalaMililani

Dental Insurance*

HDS, HMSA, United Concordia, etc (If uninsured, please write None)

Subscriber ID# or SSN

TRICARE/MILITARY: This is the "Benefits Number" on the back of your Military ID

Subscriber Name

Subscriber Date of Birth

Date

Insurance Phone Number

Relationship to Patient:*

SelfSpouseChild

Name

Date of Birth

Date

Phone Number

Dental Insurance

Subscriber ID # or SSN

TRICARE/MILITARY: This is the "Benefits Number" on the back of your Military ID

Insurance Phone Number

Person Responsible for Account:*

If person other than self, please list name:

Emergency Contact Name*

Relationship to Patient*

Emergency Contact Phone Number*

Name of Physician

Are you in good health?*

YesNo

If no, please explain:

Have you been hospitalized or had operations?*

YesNo

If yes, please explain:

Do you have any allergies?*

YesNo

If yes, please list:

Are you allergic to LATEX products? (i.e. gloves, balloons)*

YesNo

Are you currently taking any medications?*

YesNo

If yes, please list:

Have you had tonsils and adenoids removed?*

YesNo

If yes, what age did you get them removed?

Do you have frequent colds, sore throat, canker sores?*

YesNo

If yes, please explain:

Do you have frequent headaches or muscle soreness around the head and neck?*

YesNo

If yes, how do you treat the pain?

Have you been diagnosed or treated for any of the following?

Please explain above conditions or list other medical conditions:

Name of General Dentist*

If you don't currently have a dentist, write "None"

Date of Last Visit

What was done?

Cleaning, Fillings, Crown, etc.

Are any teeth sore today?*

YesNo

If yes, please explain:

Have you had any injuries to the face, mouth or teeth?*

YesNo

If yes, please explain:

Have you ever sucked your fingers or thumbs?*

YesNo

If yes, until what age?

Do you breathe primarily through your mouth?*

YesNo

Do you clench or grind your teeth?*

YesNo

If yes, please explain:

Is there clicking or pain on opening or closing the mouth?*

YesNo

If yes, please explain:

Signature*

Date*

Date

Notice of Privacy Practices Acknowledgement

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

involved in that treatment directly and indirectly.
Obtain payment from third-party payer, (insurance carriers etc
Conduct normal healthcare operations.
I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information.
I understand that this practice has the right to chance its Notice of Privacy Practices from time to time and that I may contact this practice at any time to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Patient Name

Signature

Date

Patient Photo / Video Release Form

This release is designated to give permission to Dr. Kimi S. Caswell, D.D.S., M.S. to use my photos / videos for educational and promotional purposes. I allow my digital patient photo / video series as well as any photos / videos taken in-office or at patient appreciation events to be shared with others by means of internet and print media including but not limited to: our business website, social media websites and print advertising. Dr. Caswell has permission to use my photos / videos in this manner unless I request that she no longer use them. I understand that I have the option to decline this request, and am not obligated in any way to provide permission to use these photos / videos.

I allow Dr. Kimi S. Caswell, D.D.S., M.S. to use my photos / videos for educational and promotional purposes.

Patient Name

Signature

Date

New Patient - Adult Form

ADULT INFORMATION

ADDITIONAL INFORMATION

SPOUSE

HEALTH HISTORY

DENTAL HISTORY