Child/Adolescent New Patient Information

Patient's Full Name:*

First NameLast Name

Preferred Name:

Patient's Date of Birth:*

Date

Patient's Gender: *

Patient's Interests: Sports/Activities/Things that make you smile!

Patient's School:

How did you hear about us?*

Any past or present family in treatment at our office?*

Is the patient excited about potentially starting treatment?!*

Yes!!Ehh...kindaNot at allCan be convinced!

I would like to provide parental information for:*

Mother/GuardianFather/GuardianBoth

Name:*

First NameLast Name

Phone Number:*

Area CodePhone Number

Email:*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer/Occupation:*

Marital Status/Spouse's Name:

Does the patient have dental insurance?*

Insurance Company and State:*

Example: Delta Dental of Tennessee (as it appears on your insurance card)

Subscriber's Name:*

First NameLast Name

Subsriber's Birthdate:*

Date

Subscriber's Social Security Number:*

Your security is very important to us! We only use this information to verify insurance eligibility and benefits.

Member ID:*

Group Number:*

Do you have additional insurance coverage?

Insurance Company and State:*

Example: Delta Dental of Tennessee (as it appears on your insurance card)

Subscriber's Name:*

First NameLast Name

Subsriber's Birthdate:*

Date

Subscriber's Social Security Number:*

Your security is very important to us! We only use this information to verify insurance eligibility and benefits.

Member ID:*

Group Number:*

Patient's Dentist:*

Dentist Name or NA

Estimated date of Last Exam:*

MM/YYYY

Is there any pending dental work yet to be completed?*

YesNo

Does the patient's water supply contain fluoride?*

YesNoUnsure

How often does the patient brush their teeth?*

2 or more times daily1 time per dayNot on a daily basis

How often does the patient floss?*

DailyA few times per weekAlmost never

Does the patient grind thier teeth?*

YesNoUnsure

Does the patient need antibiotics before routine dental procedures?*

YesNo

Has the patient ever had an injury to the face, mouth, teeth, or chin?*

YesNo

Do the patient smoke, vape, or use tobacco products?*

YesNo

Does the patient have any of the following habits? (Please select all that apply)*

Patient's Physician Name:*

Name of doctor or NA

Has the patient ever been diagnosed with: (Please select all that apply)*

Is the patient currently taking any medications:*

YesNo

If yes, please list medications:

Does the patient have any allergies or sensitivities:*

YesNo

If yes, please list:

Has the patient's tonsils/adenoids been removed:*

YesNo

Has the patient started her menstrual cycle? (We use the question to help determine the patient's growth status)*

YesNoDoes Not Apply

Is there anything you would like to discuss with the doctor in private?*

YesNo

Has the patient had orthodontic treatment previously with braces or clear aligners?*

YesNo

Please tell us your/the patient's main reason for seeking orthodontic treatment:*

Please tell us how important each of the following are to you *

Rows	Not	Somewhat	Important	Very	Extremely Important
Length of Treatment Time
Comfort of Treatment
Latest Technology
Clear/ Invisible
Quality of Treatment
Low Down Payment
Interested in Starting Within the Month

Name of Parent/ Legal Guardian Giving Consent: *

First NameLast Name

SECTION B: TO THE PATIENT - PLEASE READ THESE STATEMENTS CAREFULLY

PURPOSE OF CONSENT: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations.

NOTICE OF PRIVACY PRACTICES: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activities and healthcare operations of the uses and disclosures we may make of your protected health information and of other important matters about your protected health information. A copy of our notice is available upon request with this consent. We encourage you to read it carefully and completely before signing this consent.

OFFICE PROCEDURES: As a part of your complimentary consultation our office will take x-rays and photographs of your teeth. This is for diagnostic purposes and will not be billed to you or your insurance company. It is near impossible for our doctors to give accurate treatment plans without these records.

USE OF RECORDS: Cox Orthodontics has the right to use patient photographs, x-rays, videos, and other photographic reproduction for the purpose of communication with your current and future dental and medical professionals. Our doctors also reserve the right for records obtained in our office to be used for professional, academic, patient education, and practice promotion. This includes, but is not limited to use on the Cox Orthodontics website, brochures, and social media sites.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices we will make available upon request a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

RIGHT TO REVOKE: You will have the right to revoke this consent at any time by giving us written notice or your revocation submitted to the contact person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation and that we may decline to treat you or to continue treating you if you revoke this consent.

SECTION C: SIGNATURE

I HAVE HAD FULL OPPORTUNITY TO READ AND CONSIDER THE CONTENTS OF THIS CONSENT FORM AND YOUR NOTICE OF PRIVACY PRACTICES. I UNDERSTAND THAT BY SIGNING THIS CONSENT FORM I AM GIVING MY CONSENT TO YOUR USE AND DISCLOSURE OF MY PROTECTED HEALTH INFORMATION TO CARRY OUT TREATMENT, PAYMENT ACTIVITIES AND HEALTH CARE OPERATIONS

Parent/ Legal Guardian Signature*

Date*

Date

Child/Adolescent New Patient Information

Parent/Guardian Information

Dental Insurance Information

Dental History

Medical History

Orthodontic Information

Consent for use and disclosure of health information