New Patient Form (Under 18)

New Patient Form (Under 18)
PATIENT
Date

MonthDayYear
Date
Patient's Name

First NameLast Name
Preferred Name
Hobbies, Activities
Birthdate

MonthDayYear
Date
Sex
Social Security No.
School
Grade
Email Address
example@example.com
Home 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.
PARENT/GUARDIAN
Custodial Parent(s) Name(s)
Patient lives with... (Please check all that apply)

MotherFatherStepmotherStepfatherGrandparent(s)Other
Father's Full Name

First NameLast Name
Title
Occupation
Email Address
example@example.com
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone (if different)
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Mother's Full Name

First NameLast Name
Title
Occupation
Email Address
example@example.com
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone (if different)
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
DENTIST
Patient's Dentist
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last Seen

MonthDayYear
Date
Reason
Next Appointment

MonthDayYear
Date
Is the Patient seeing any other Dentists/Dental Specialists now?

YesNo
If Yes, what are their names and reasons for being seen?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GENERAL INFORMATION
What concerns you about your child's teeth?
What concerns your child about their teeth?
How does your child feel about orthodontic treatment?
Who suggested that your child might need orthodontic treatment?
Why did you select our office?
Describe any previous orthodontic treatment or consultations.
Does your child play a musical instrument?

YesNo
Please list any siblings the patient may have, their ages, and if they have undergone orthodontic treatment.
FINANCIAL RESPONSIBILITY
Who is financially responsible for this account?
Address (if different than Patient's)

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 Address(es)
example@example.com
Social Security No.
Employer
Who will be responsible for bringing the patient to their orthodontic appointments?
DENTAL INSURANCE
Primary Policyholder's Full Name

First NameLast Name
Birthdate

MonthDayYear
Date
Social Security No.
Relationship to Patient
Address (if different than Patient's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (if different)
Please enter a valid phone number.
Employer
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company
Group #
ID #
Does this policy have orthodontic benefits?

YesNoI Don't Know
Secondary Policyholder's Full Name

First NameLast Name
Birthdate

MonthDayYear
Date
Social Security No.
Relationship to Patient
Address (if different than Patient's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (if different)
Please enter a valid phone number.
Employer
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company
Group #
ID #
Does this policy have orthodontic benefits?

YesNoI Don't Know
MEDICAL INSURANCE
Policyholder's Full Name

First NameLast Name
Insurance Company
PHYSICIAN
Patient's Physician
City, State
Last Seen

MonthDayYear
Date
Reason
Next Appointment

MonthDayYear
Date
Most Recent Physical Exam

MonthDayYear
Date
Other Physicians/Health Care Providers Being Seen Now:
Your answers are for office records only and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.

For the following, please mark Yes, No, or Don't Know/Understand (DK/U).

	Yes	No	DK/U
Birth Defects/Hereditary Problems?
Bone Fractures or Major Injuries?
Any Injuries to the Face, Head, Neck?
Arthritis or Joint Problems?
Cance, Tumor, Radiation Treatment or Chemotherapy?
Endocrine or Thyroid Problems?
Diabetes or Low Sugar?
Kidney Problems?
Immune System Problems?
History of Osteoporosis?
Gonorrhea, Syphilis, Herpes, STD's?
AIDS or HIV Positive?
Hepatitis, Jaundice, or Other Liver Problems?
Polio, Mononucleosis, Tuberculosis, Pneumonia?
Seizures, Fainting Spells, Neurologic Problems?
Mental Health Disturbance or Depression?
History of Eating Disorder (Anorexia, Bulimia)?
Frequent Headaches or Migraines?
High or Low Blood Pressure?
Excessive Bleeding or Bruising, Anemia?
Chest Pain, Shortness of Breath, Tire Easily, Swollen Ankles?
Heart Defects, Heart Murmur, Rheumatic Heart Disease?
Angina, Arteriosclerosis, Stroke or Heart Attack?
Skin Disorder (Other than Common Acne)?
Does your child eat a well-balanced diet?
Vision, Hearing, or Speech Problems?
Frequent Ear Infections, Colds, Throat Infections?
Asthma, Sinus Problems, Hayfever?
Tonsil or Adenoid Condition?
Does your child frequently breathe through their mouth?
Has your child ever taken intravenous bisphosphonates such as Zometa (Zolendronic acid), Aredia (pamidronate), or Didronel (etidronate) for bone disorders or cancer?
Has your child ever taken oral bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate), or Didronel (etidronate) for bone disorders?

Has your child had allergies or reactions to any of the following?

	Yes	No	DK/U
Local Anesthetics (Novocaine, Lidocaine, Xylocaine)
Latex (Gloves, Balloons)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin
Other Antibiotics
Metals (Jewelry, Clothing Snaps)
Acrylics
Plant Pollens
Animals
Foods

Now, or in the past, has your child had

	Yes	No	DK/U
Erupting Teeth Very Early or Very Late?
Primary (Baby) Teeth Removed That Were Not Loose?
Permanent or Extra (Supernumerary) Teeth Removed?
Supernumerary (Extra) or Congenitally Missing Teeth?
Chipped or Injured Primary Teeth?
Any Sensitive or Sore Teeth?
Any Lost or Broken Fillings?
Jaw Fractures, Cysts, Infections?
Any Teeth Treated with Root Canals or Pulpotomies?
Frequent Canker Sores or Cold Sores?
History of Speech Problems or Speech Therapy?
Difficulty Breathing Through Nose?
Mouth Breathing Habit or Snoring at Night?
History of Speech Problems?
Frequent Oral Habits (Sucking Finger, Chewing Pen, etc.)?
Teeth Causing Irritation to Lip, Cheek, or Gums?
Tooth Grinding or Clenching?
Clicking, Locking in Jaw Joints?
Soreness in Jaw Muscles or Face Muscles?
Has your child been treated for TMJ/TMD problems?
Any broken or missing fillings?
Any serious trouble associated with previous dental treatment?
Has your child ever been diagnosed with gum disease or pyorrhea?

PATIENT HEALTH INFORMATION
Do you think that any of your child's activities affect their face, teeth, or jaws? How so?
List any medication, nutritional supplements, herbal medications, or non-prescription medicines, including fluoride supplements that your child may take.
Does your child take antibiotic pre-medication before any dental procedures?

YesNo
Does your child have (or ever had) a substance abuse problem?

YesNo
Does your child chew or smoke tobacco?

YesNo
Have you noticed any unusual changes in your child's face or jaws?

YesNo
FAMILY MEDICAL HISTORY
Have the parents/siblings ever had any of the following health problems?

Bleeding DisordersDiabetesArthritisSever AllergiesUnusual Dental ProblemsJaw Size Imbalance
If Yes, please describe
How often does your child brush their teeth?
How often does your child floss their teeth?
RELEASE AND WAIVER

I authorize release of any information regarding my child's orthodontic treatment to my dental and/or medical insurance company.
Parent/Guardian Signature

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Date

MonthDayYear
Date
I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes In my child's medical or dental health.
Parent/Guardian Signature

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Date

MonthDayYear
Date

PRIVACY NOTICE
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your protected health information (i.e., individually identifiable information such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed to us in one or more of the following respects:
- To other health care providers (i.e., your general dentist oral surgeon, etc.) in connection with our rendering orthodontic treatment to you (i.e., to determine the results of cleanings, surgery, etc);
- To third-party payers or spouses (i.e., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) ni order to obtain payment of your account (i.e., to determine benefits, dates of payment, etc.);
- To certifying licensing and accrediting bodies (i.e., The American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation;
- Internally, to all staff members who have any role in your treatment; and/or,
- To other patients and third parties who may see or overhear incidental
  disclosures about your treatment, scheduling, etc.;
- To your family and close friends involved in your treatment; and/or;
- We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke.

Under the new privacy rules, you have the right to:
- Request restrictions on the use and disclosure of your protected health information;
- Request confidential communication of your protected health information;
- Inspect and obtain copies of your protected health information by asking us;
- Amend or Modify your protected health information in certain circumstances;
- Receive an accounting of certain disclosures made by us of your protected
  health information; and
- You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our Privacy contact person at our office address) or the United States Secretary of Health and Human Services. (Which must be filed within 180 days of the violation.)
We have the following duties under the privacy rules:
- By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information;
- To abide by the terms of our Privacy Notice that is currently in effect;
- To advise you of our right to change the terms of this Privacy Notice and to make the new notice provisions effective for all protected health information maintained by us and that if we do so, we will provide you with a copy of the revised Privacy Notice.
Please note that we are not obligated to:
- Honor any request by you to restrict the use of your protected health information;
- Amend your protected health information if, for example, it is accurate and
  complete; or,
- Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.
This privacy notice is effective as of the date of your signature. If you have any questions about the information in this notice, please ask for our Privacy contact person or direct your questions to this person at our office address. Thank You.

PATIENT ACKNOWLEDGEMENT

I hereby acknowledge that I have received and reviewed a copy of this Privacy Notice.
Signature

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Date

MonthDayYear
Date

PRIVACY CONSENT
This form is optional under the new patient privacy regulations recently issued by the United States Department of Health and Human Services. We have elected to use this form. Prior to commencing your orthodontic treatment, you should review, sign, and date this form.

Your protected health information (i.e., individually identifiable information such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used in connection with your treatment, payment of your account or health care options (i.e., performance reviews, certification, accreditation, and licensure).

You have the right to review our office's privacy notice prior to signing this Consent, a copy of which was given to you with this consent.

You have the right to request restrictions on the use of your protected health information. However, we are not required to, and may not honor your request.
We may amend the attached privacy notice at any time. If we do, we will provide you with a copy of the changes, and the changes may not be implemented prior to the effective date of the revised notice.

You may revoke this consent at any time in writing. However, such revocation will not be effective to the extent that any action has been taken in reliance on this consent.

Thank you for your cooperation. Please let us know fi you have any questions.
Signature

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Patient Name

First NameLast Name
Date

MonthDayYear
Date

INSURANCE CO-PAYMENT POLICY
As a courtesy and convenience for our patients, this office agrees to accept insurance co-payment as a means of prearrangement for payment of the orthodontic fee. We must, however, have agreement and understanding of our policy regarding the issue.

The patient or responsible party must take responsibility for confirming eligibility for orthodontic benefits. This can be done by having the responsible party call their designated representative to determine eligibility and amounts of coverage. It would be suggested that the responsible party request a written authorization from their insurance carrier. Another means of doing this would be for our office to submit a pre-treatment authorization on the patient's behalf. This takes more time since we would be waiting on return mail.

The responsible party may also choose to begin treatment before confirming eligibility for orthodontic benefits by signing the following statement.
I understand that I am responsible for the full orthodontic fee for Patient Name regardless of the possible insurance benefits payable. I choose to make financial arrangements using my anticipated insurance benefits for co-payment. I further understand that in the event the insurance determines that there are reduced or no benefits, then I would need to revise my current financial arrangement so that the full payment for the treatment fee will be satisfied in the estimated active treatment time frame.
Signature

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INSURANCE INFORMATION
Policyholder's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to Patient
Social Security No.
Employer
Insurance Company
Claims Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy #
Group #
Subscriber ID

PHOTO RELEASE
Option 1: I give my permission for Camellia Orthodontics to display my/my child's photo in the following ways:
- Bulletin Board in Office
- Camellia Orthodontics Facebook/Instagram Page
- Camellia Orthodontics Website
Option 2: I do not wish to have my/my child's photo displayed by Camellia Orthodontics in any way.
What option do you select?

Option 1Option 2
I understand that signing this release is optional and Camellia Orthodontics will not post my photos without my permission.
Patient Name

First NameLast Name
Parent Name (If Patient is a Minor)

First NameLast Name
Patient/Parent Signature

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New Patient Form (Under 18)

PATIENT

PARENT/GUARDIAN

DENTIST

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL INSURANCE

PHYSICIAN

PATIENT HEALTH INFORMATION

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER

PRIVACY NOTICE

PRIVACY CONSENT

INSURANCE CO-PAYMENT POLICY

INSURANCE INFORMATION

PHOTO RELEASE