Adult New Patient Form

Adult New Patient Form
Patient Name*

First NameLast Name
Preferred Name
Birthdate*

MonthDayYear
Date
Age*
Sex*
Social Security Number*
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Employer/Occupation
Business Phone
Please enter a valid phone number.
Marital Status
Spouse's Name

First NameLast Name
Employer/Occupation
Business Phone
Please enter a valid phone number.
Name of Dentist
Date of Last Dental Visit

MonthDayYear
Date
How did you hear about our office?
Other family members treated at this office?
PERSON RESPONSIBLE FOR ACCOUNT*
Primary Insurance Information
Policy Holder's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number
Relationship to Patient
Employer
Work Phone
Please enter a valid phone number.
Insurance Company
ID #
Group #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number on Insurance Card
Please enter a valid phone number.
Secondary Insurance Information
Policy Holder's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number
Relationship to Patient
Employer
Work Phone
Please enter a valid phone number.
Insurance Company
ID #
Group #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number on Insurance Card
Please enter a valid phone number.
Medical Information
Your answers are for office records only and are confidential. A thorough medical and dental history is essential to a complete orthodontic evaluation.
Have you ever had any of the following? Please check all that apply:

HIV/AIDSAnemiaArthritisArtificial JointsAsthmaBlood DiseaseBrain InjuryBone DisorderChest Pain, Shortness of BreathChemotherapyCancerDiabetes or low blood sugarDizzinessEarachesEmotional ProblemsEpilepsyExcessive BleedingFainting/DizzinessGlaucomaHay FeverFrequent Headaches or MigrainesHead InjuriesHeart Murmur, Heart DefectsHepatitis, or Liver ProblemsHigh or Low Blood PressureJaundiceKidney DiseaseLiver DiseaseMental DisordersMitral Valve ProlapseNervous DisordersPacemakerPregnancyRadiation TreatmentRemoval of Adenoids or TonsilsRespiratory ProblemsRheumatic FeverRheumatismSinus ProblemsSpeech ProblemsStomach ProblemsSeizures, Neurologic ProblemsStrokeThyroid ProblemsTuberculosisTumorsUlcersVision, Hearing ProblemsVenereal DiseaseOther
Have you been admitted to a hospital or needed emergency care during the past two years?

YesNo
If yes, please explain:
Have you ever taken Biphosphonate medication (e.g., Fosamax, Actonel, Boniva, Skelid or Didronel for bone disorders)?

YesNo
If yes, what medication and length of time on the medication:
Are you now under the care of a physician?

YesNo
Name of Physician
Phone Number
Please enter a valid phone number.
Do you currently have (or ever had) a substance abuse problem?

YesNo
Do you chew or smoke tobacco?

YesNo
List any medication, nutritional supplements, herbal medications or non-prescription medicines that you currently take:
Are there any medical conditions we have not listed that you feel we should be aware of?

YesNo
If yes, please explain:
Dental History
What concerns you most about your teeth?
Do you have any current dental problems?
Have you ever had orthodontic treatment?

YesNo
If yes, please explain:
Has anyone in your family received orthodontic treatment?

YesNo
If yes, who?
Do you feel nervous about having dental treatment?

YesNo
If yes, what is your biggest concern?
Have you ever had an upsetting dental experience?

YesNo
If yes, please describe:

Please answer the following:

	Yes	No
Presently in any dental pain?
Sensitive teeth?
Gums bleed or hurt?
Permanent or extra (supernumerary) teeth removed?
Noticed any loose teeth or changes in your bite?
Any injuries to the face, mouth, or teeth?
Bleeding gums, bad taste, or mouth odor?
Abnormal swallowing (tongue thrust)?
Mouth breathing/snoring at night?
Food impaction between the teeth?
History of speech problems/speech therapy?
Clench/grind your teeth?
Have clicking or popping in your jaw?
Difficulty opening/closing your mouth?
Ever been told you have a TMJ problem?
Get frequent headaches?

I have read the above questions and understand them. To the best of my knowledge, all of the preceding answers and information provided are true and correct. I will not hold the orthodontist or any member of the staff responsible for any errors or omissions that I have made in the completion of this form. I will notify the orthodontist of any changes in my medical and dental health.
Signature of Patient, Parent, or Guardian*

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MonthDayYear
Date
Consent for Services
I certify that the information provided is accurate and will be relied upon for granting credit and providing services. I understand that I am financially responsible for the charges not covered by or paid by my insurance for whatever reason.

By signing below, I authorize that you may verify and exchange information on me and any additional applicants, including requiring reports from credit reporting agencies.

I authorize payment directly to the orthodontist of any group insurance benefits otherwise payable to me. I understand that I am financially responsible for any charges not covered by this authorization. I authorize release of any information relating to any dental claim or claims.

I hereby authorize the orthodontist or designated staff to take X-rays, study models, photographs and other diagnostic aids deemed appropriate by the orthodontist to
make a thorough diagnosis.

I agree to be responsible for payment of all services on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements
have been made.
Signature of Patient, Parent, or Guardian*

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Date*

MonthDayYear
Date

Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION

PLEASE REVIEW IT CAREFULLY THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations, for example:
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you, or to family and friends you approve.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health information in connections with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. You also have the right to request restriction on disclosure of PHI (Personal Health Information), or alternative means of communication to ensure privacy.
Marketing Health-Related Services: We will not use your health information for marketing communications without your written consent.
Required by Law: We may use or disclose your health information when we are required to do so by law or national security activities.
Abuse or Neglect: We may disclose your health information to appropriate authorities when we suspect abuse or neglect.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

PATIENT RIGHTS
Access: You have the right to look at or get copies of your health information with limited exceptions. Requests of a patient’s records must be made in writing and can take up to ten business days to process. If you request copies, we will charge you a reasonable fee to locate and copy your information, and postage if you want the copies mailed to you.
Amendment: You have the right to request that we amend your health information.

QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you are encouraged to make any complaints to us directly. You also may submit a written complaint to the U.S Department of Health and Human Services. We support your right to the privacy of your health information.

PATIENT ACKNOWLEDGEMENT OF REVIEWING AND UNDERSTANDING OF NOTICE OF PRIVACY PRACTICES AND CONSENT FOR NECESSARY USE OF PERSONAL HEALTH INFORMATION
I Print Patient or Parent or Legal Guardian Name* , consent to the use and disclosure of the patient's personal health information by this office for treatment, billing/payment, and healthcare operations as outlined in the Notice of Privacy Practices.
Signature of Patient, Parent, or Legal Guardian*

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Date
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Adult New Patient Form

Primary Insurance Information

Secondary Insurance Information

Medical Information

Dental History

Consent for Services

Notice of Privacy Practices