• Patient Information Form

    Patient Information Form

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Birthdate*
     - -
  • Gender

  • Responsible Party Information

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

  • If patient is under 18, please complete the following section.

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

  • Emergency Information

  • Format: (000) 000-0000.

  • Medical History

    Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.
  • Format: (000) 000-0000.
  • Are you taking any medication?
  • Are you allergic to any medication?
  • Do you have a history of any major illness?
  • Have you had any major operations?
  • Have you ever been involved in a serious accident?
  • Please check any of the following that you have had or currently have:

  • Dental History

  • Date of Last Visit
     - -
  • Are you presently in any dental pain?
  • Have there been any injuries to the face, mouth, or teeth?
  • Is any part of your mouth sensitive to temperature?
  • Is any part of your mouth sensitive to pressure?
  • Do you have any type of thumb or tongue habit?
  • Are you a mouth breather?
  • Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
  • Are you aware of your jaws clicking or popping?

  • By providing your signature below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

  • Date
     - -

  • HIPAA Consent Form

  • Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. 

     

    The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature you have reviewed our notice before signing this consent. 

     

    The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. 
     

    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 a revocation will not be retroactive. 

     

    By signing 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. 

  • May we phone, email, or send a text to you to confirm appointment?
  • May we leave a message on your answering machine at home or on your cell phone?
  • May we discuss your medical condition with any members of your family?

  • This Consent was signed by:

  • Date
     - -
  • Should be Empty: