Patient Health History Update

  • Patient History Update

  • Date
     - -
  • Date of Last Dentist Exam
     - -

  • The following questions are designed to update your health history, insurance, and personal information, and to make us aware of any changes regarding your appointments in our office:

  • Does the patient have or has the patient had any of the following? (Please check all that apply.)
  • Is the patient pregnant?
  • Does the patient require antibiotics prior to treatment?
  • Has there ever been trauma to the patient's face/teeth?
  • Is the patient presently under the care of a physician for an illness or disease?
  • Does the patient have a bleeding tendency or do wounds heal slowly?
  • Is the patient allergic to nickel, latex or any drugs or medications?
  • Is the patient taking any medications?

  • Responsible Party Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Other than the responsible party, who else can bring the patient to their appointment(s), discuss financials, or schedule appointments?

  • To the best of my knowledge, the questions on this update form have been accurately answered. I understand that providing incorrect information can be dangerous to my health and that it is my responsibility to inform Byrne Orthodontics of any changes in my medical status. I also authorize Byrne Orthodontics to perform any necessary orthodontic services that I may need.

  • Date
     - -

  • Patient Consent for the Use & Disclosure of Protected Health Information

    I have read and received the Notice of Privacy Practices and hereby give my consent for Byrne Orthodontics to use and disclose health information (PHI) about me/my child to carry out treatment, payment, and healthcare operations (TPO).

  • Date
     - -
  • Do you dental insurance?

  • Updated Insurance Form

    ***This is NOT a guarantee of benefits or payment. Actual benefits cannot be determined until actual claim is received by carrier. As per contract patient is responsible for any balance denied or rejected by insurance carrier ***
  • Patient's D.O.B.
     - -
  • Policyholder's D.O.B.
     - -
  • Format: (000) 000-0000.
  • Effective Date of New Insurance
     - -

  • Information & Payment Authorization Release

  • I authorize the release of any information relating to this claim and understand that I am responsible for all costs of dental treatment.

  • Date
     - -

  • I hereby authorize payment directly to Byrne Orthodontics of the group insurance benefits otherwise payable to me.

  • Date
     - -
  • Should be Empty: