NP Form - Little Smiles

Patient Information
Patient Name*
Today's Date*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Age*
Cell Phone
Home Phone
Address*

Address

Street Address Line 2

CityState

Zip
Name of Primary Guardian*
Date of Birth*

MonthDayYear
Date
Relationship to Patient
Employer
Work Phone
Email*
example@example.com
SSN
Responsible Party
Name of Secondary Guardian*
Date of Birth*

MonthDayYear
Date
Relationship to Patient
Cell Phone
Home Phone
SSN
Employer*
Address

Address

Street Address Line 2

CityState

Zip
Work Phone
Email
example@example.com
Primary Dental Insurance
Name of Insurer
Group Name
Name of Primary Person Covered by this Insurance
Date of Birth of Primary Person

MonthDayYear
Date
SSN
Secondary Dental Insurance
Name of Insurer
Group Name
Name of Primary Person Covered by this Insurance
Date of Birth of Primary Person

MonthDayYear
Date
SSN
Tertiary Dental Insurance
Name of Insurer
Group Name
Name of Primary Person Covered by this Insurance
Date of Birth of Primary Person

MonthDayYear
Date
SSN
Primary Care Provider Name
Phone
Preferred Pharmacy with Location
List Business Name and Address
Referred By (Please Select):

Social MediaFriends/FamilyGoogleMailerBillboardDoctorDrive/Walk ByWord of MouthOther
If referred by 'doctor,' please list name and practice below:
Emergency Contact
Name*
Relationship*
Phone*

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
**You may refuse to sign this acknowledgment**

By signing below, I am stating that I have received a copy of this office's Notice of Privacy Practices:
Signature of Patient/Legal Guardian

Clear
Please Print Patient Name
Date

MonthDayYear
Date
The notice contains a patient's rights section describing your rights under the law. You certify by your signature that you have reviewed our notices before signing this consent. The terms of the notices are subject to change.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you, however, such revocation will not be retroactive.

By submitting this form, I understand that:
- Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
- The practice reserves the right to change the privacy policy as allowed by law.
- The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
- The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
- The practice may condition receipt of treatment upon execution of this consent.
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. You may communicate with the following individuals relating to the patient's medical or payment information:
Should be Empty:

	Yes	No	Text
Were any x-rays taken at patient's last dental visit?
Has patient had any problems with dental exams or treatment in the past?
Has patient had any cavities in the past?
Does patient brush their teeth daily?
Does patient currently take fluoride supplement tablet, gels, rinses, etc.?
Does patient floss their teeth daily?
Has patient ever received local anesthetic?
Has patient ever had sealants placed?
If applicable: Has patient been diagnosed with tooth decay in past two years?
Has patient experienced any trauma to the teeth? (falls, blows, chips, etc.) Please explain by using the text box.
Has patient ever sucked thumbs or fingers?
Does patient have speech problems?
Has patient ever been informed of any extra or missing teeth?
Has patient ever had a previous orthodontic exam?
Has any family members ever needed orthodontics in the past?
Does patient have any pain in their jaw?
Does patient have any popping or clicking of the jaw joint?

Patient Information

Responsible Party

Primary Dental Insurance

Secondary Dental Insurance

Tertiary Dental Insurance

Emergency Contact

Confidential Patient Medical and Dental History

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES