Welcome to Lifetime Orthodontics!

Welcome to Lifetime Orthodontics!

Please complete all of the necessary forms prior to your scheduled consultation to ensure a faster and more enjoyable experience.
Patient's Name*

First NameMiddle NameLast Name
Preferred First Name
Today's Date

MonthDayYear
Date
Patient's Date of Birth*

MonthDayYear
Date
Patient's Age
Patient's Sex*

MaleFemaleOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Relationship to Patient*
Phone Number*
Primary Phone Type
Is the address for the primary contact the same as the patient?*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Dental Insurance

Providing your dental insurance before the exam will help us assess your eligibility for benefits. Please ensure all fields are filled out correct
Do you have Dental Insurance?

NoYesYes, but I don't know it right now
Policy Holder #1
Policy Holder's Name
Employer
Dental Insurance Company
ID# or SSN*
Date of Birth
Upload a photo of your insurance card: Both front and back.

Browse Files

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Policy Holder #2
Policy Holder's Name
Employer
Dental Insurance Company
ID#
Date of Birth

Patient Information
Why is the patient seeking treatment?*
How were you referred to our office?*
Who may we thank for referring you to our office? *
What part of the internet specifically did you find us on?*
What's the other way you heard about our practice? *
Did you hear about us in any other ways?*

YesNo
How else did you hear about us?*
Are there other family members that have been treated at this practice?*

YesNo
Please list the family member(s) name(s) *
Patient's current school name (if applicable):
Patient's current grade level (if applicable):
Please list any patient interests, hobbies, musical instruments, and/or sports:

PRIVACY NOTICE

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
GERALD W. WESLEY, DDS, MS

Board Certified Orthodontist
Your protected health information (i.e., individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:
• To other health care providers (i.e. your general dentist, oral surgeon etc.) in connection with our rendering orthodontic treatment to you (i.e. to determine the results of cleanings, surgery, etc.)
• To third party payers or spouses (i.e. insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e. to determine benefits, dates of payment, etc.)
• To certifying, licensing and accrediting bodies (i.e. the American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation;
• To your family and close friends involved in your treatment, and/or,
• We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke.

Under the new privacy rules, you have the right to:
• Request restrictions on the use and disclosure of your protected health information;
• Request confidential communication of your protected health information;
• Inspect and obtain copies of your protected health information through asking us;
• Amend or modify your protected health information in certain circumstances;
• Receive an accounting of certain disclosures made by us of your protected health information; and,
• You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our Privacy Contact Person at our office address) or the United States Secretary of Health and Human Services (which must be filed within 180 days of the violation).

We have the following duties under the privacy rules:
• By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information;
• To abide by the terms of our Privacy Notice and to make the new notice provisions effective for all protected health information maintained by us, and that if we do so, we will provide you with a copy of the revised Privacy Notice.
Please note that we are not obligated to:
• Honor any request by you to restrict the use or disclosure of your protected health information;
• Amend your protected health information, for example, it is accurate and complete; or,
• Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.

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 for our Privacy Contact Person or direct your questions to this person at our office address. Thank you.
Date*

MonthDayYear
Date
Parent / Patient Name*

First NameLast Name
Parent / Patient Signature: *

Clear

PLEASE BE SURE TO CLICK "SUBMIT" AT THE BOTTOM OF THIS PAGE

We want to thank you for choosing Lifetime Orthodontics! Do you realize that this is the first step of your smile journey!? We assure you that this will be an experience unlike any you have ever experienced in a dental or medical office before.

Dr. Wesley and his team have reserved one (1) hour to thoroughly examine you. This appointment is completely complimentary.

Complete your health history forms.

It is important that we get to know a little bit about you before we meet you. If you got to this page then you already have completed this!

Prepare to get started!

We know that you’re busy and we understand your time is valuable. For your convenience, if orthodontic treatment is recommended for you, we have reserved time to get you started the same day as your consultation appointment.

Help us develop a custom financing plan just for you.

With or without insurance, orthodontic treatment usually requires some out of pocket payments. We pride ourselves on never letting affordability stand in the way of a life-changing smile. If you have not already given your insurance information please bring any insurance cards with you to this appointment. Please consider a down payment and a monthly payment that works for your budget and we will do the rest. If another party will be assisting you in the financial decision it is suggested that they attend the visit with you.

Diagnostic records will be taken before the meeting with Dr. Wesley. These records include:
- Photographs of your mouth and face
- Cephalometric x-ray of your head showing the relative position of the teeth and supporting structure
- Panoramic x-ray of all teeth which is needed to evaluate the root structure and bone surrounding the teeth
If you are unable to keep this appointment, please call the office as soon as possible to reschedule.

We look forward to seeing you!
Please click submit when you have answered all of the questions. Thank you!
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Welcome to Lifetime Orthodontics!

Dental Insurance

Medical History

Medical History:

Pediatric Sleep Questionnaire:

Sleep Related Disorder Questionnaire:

Patient Information

Additional Information

PRIVACY NOTICE

GERALD W. WESLEY, DDS, MS