FIO Child Patient Form 5/2022

PATIENT INFORMATION FORM - CHILD
PATIENT INFORMATION
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate*

MonthDayYear
SS#
Occupation
Employer
Work #
Home #
Cel #*
Email*
Other family members seen by us:
Whom may we thank for referring you to our office?*
Dentist Information*
Name
Street Address

CityState / Province

Postal / Zip Code
*
Phone Number
Last Dental Visit

MonthDayYear
Date
INSURANCE INFORMATION
INSURANCE: Insurance information must be filled out completely before you come in for your initial appointment in order to accurately determine your orthodontic benefits and subsequently bill your insurance. (Note: Orthodontics is Dental and TMJ is Medical)
Do you have Orthodontic Insurance?*
Provider*
ID #
Insurance Address
Ph #
Name of Subscriber
Subscriber Birthdate

MonthDayYear
Subscriber SS #
Do you have a Secondary Insurance?*
Provider
Group/Plan #
Insurance Address
Ph #
Secondary Subscriber
Subscriber Birthdate

MonthDayYear
Subscriber SS #
Upload a photo of your Insurance Card

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RESPONSIBLE PARTY INFORMATION
NOTE: If separated/divorced the responsible party of the child is the custodial parent. The person responsible for account and signing contract is the only person legally able to acquire any information regarding patient. If responsible party has legal custody of a person under 18 and the relationship to the person is not mother/father, please provide information below.
Name

First NameLast Name
Relationship to Patient
Employer
Occupation
Cel #
Work #
SS #
Birthdate

MonthDayYear
Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Information

Step MotherGuardian
Name

First NameLast Name
Birthdate

MonthDayYear
Father's Information

Step FatherGuardian
Name

First NameLast Name
Birthdate

MonthDayYear
Who is reponsible for making appointments?
Name
Relationship to Patient
Cel #
If you are not the Patient or Responsible Party filling out this form, please provide:
Name

First NameLast Name
Relationship to Patient
Address
Ph #
Signature*

Clear
Today's Date

MonthDayYear
Date

PRIVACY HIPAA CONSENT FORM
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:
- Treatment (including direct or indirect treatment by other healthcare providers
  involved in my treatment);
- Obtaining payment from third party payers (e.g. my insurance company);
- The day-to-day healthcare operations of your practice.
I have also been informed of and given the right to review and request a copy of your Notice of Privacy practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I Understand that you reserve the right to obtain the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care Operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date, the revoke of this consent is not affected.
Signature of Patient/Parent/Guardian*

Clear
Print Patient Name
Date

MonthDayYear
Date
Should be Empty:

	Mild	Moderate	Severe
1. Chronic Pain
2. Facial Pain
3. Gum Recession
4. Gum Problems
5. Headaches
6. Jaw Dysfunction
7. Jaw Pain

	No	Yes
1. Mouth breathing while awake or asleep
2. Problem sleeping through the night
3. Sleepiness or tire easily ……………
4. Problem focusing ………………….
5. Frequent headaches ……………….
6. Snoring ………………………………

	No	Yes
1. Clenching ...........................
2. Dental Anxiety ....................
3. Difficulty Chewing................
4. Finger Sucking ...................
5. Grinding...............................
6. Lip Biting ............................
7. Smoking ..............................
8. Sore Teeth ..........................
9. Speech Problems ...............
10. Tongue Thrusting ...............

PATIENT INFORMATION FORM - CHILD

PATIENT INFORMATION

INSURANCE INFORMATION

RESPONSIBLE PARTY INFORMATION

ORTHODONTIC PATIENT HEALTH QUESTIONNAIRE

I. SUBJECTIVE COMPLAINTS AND CONCERNS

II. MEDICAL DENTAL HISTORY

III. ORTHODONTIC HISTORY

IV. OTHER INFORMATION

PRIVACY HIPAA CONSENT FORM