pinnaclepeakorthodontics.com - Adult Questionnaire

GET ACQUAINTED QUESTIONNAIRE

ADULT
The following information is needed to enable us to give you the most consideration and best services possible. Please have ALL sides of the form filled out BEFORE your appointment. This information is of course confidential. Thank you.
Patient’s Full Name

First NameLast Name
Preferred Name
Social Security Number
Sex:

MaleFemale
Age:
Birthdate:

MonthDayYear
Date
Cell Phone #
Please enter a valid phone number.
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Height
Weight
lbs
Occupation
Employer
# YRS Employed
Business Ph #
Please enter a valid phone number.
Email address
example@example.com
Patient’s Dentist
Phone Number
Please enter a valid phone number.
Date of last cleaning and check-up

MonthDayYear
Date
Had unfavorable reaction to dental care?
What is your primary concern
What are your feelings about braces?
Have you ever been seen by an orthodontist?
How many children do you have?
Ages
Do they have any orthodontic problems?
Have they had any orthodontic treatment?
Name(s) of family member(s) treated in our practice
Whom may we thank for referring you to our office?

INSURANCE VERIFICATION FORM
In order to assist you in verifying your orthodontic insurance benefit, the following information

MUST BE FILLED OUT COMPLETELY:
Patient's Name
Date of Birth

MonthDayYear
Date
Name of Person Who Carries the Insurance:
Date of Birth

MonthDayYear
Date
Social Security #
ID#
Phone Number
Please enter a valid phone number.
Employed By:
Business Phone #:
Please enter a valid phone number.
Address:
Insurance Company:
Policy/Group #:
Address of Insurance Company:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ins Company Ph#
Please enter a valid phone number.
If patient is covered under another Dental Plan, please complete another insurance form.

I hereby authorize release of any information relating to this claim and authorize payment directly to the named orthodontist of the insurance benefits.
Signature

Clear
Date

MonthDayYear
Date

Photo Release
I, Name consent to the use of my personal image and likeness, including but not limited to images representing and depicting the treatment provided to me and the effect thereof, by Pinnacle Peak Orthodontics for any lawful use Pinnacle Peak Orthodontics deems appropriate, including treatment, advertising his/her/ its services to the general public (including via social media and electronic media), illustration, and publication to the public at large for educational purposes.

I hereby relinquish any and all rights to my likeness or any image of me obtained by any photographic or digital means by Pinnacle Peak Orthodontics during the course of my treatment. I understand that I am entitled to no consideration, remuneration or payments for the use of my image in any advertising, promotional or education materials.

I understand any images or likeness of me may be altered prior to use if deemed appropriate by Pinnacle Peak Orthodontics. I understand and agree that I have no right to be consulted about or approve of any such alterations before my image is used.

I understand that Pinnacle Peak Orthodontics will make all reasonable efforts to safeguard my privacy as required by applicable law, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand, however, that Siree Orthodontics cannot guarantee my complete privacy in the event my image or likeness is used by third parties.

I understand and agree that Pinnacle Peak Orthodontics may use information regarding my health condition including information regarding my diagnosis, course of treatment, my date of birth and or age/and my other relevant medical conditions, in describing the treatment rendered to me as depicted in any image of me.

I understand that Pinnacle Peak Orthodontics may not condition the rendition of treatment to me upon my authorization of the use of my image and/or likeness. I have read the foregoing in its entirety and understand its terms.
Patient Name
Patient/Guardian Signature

Clear
Date

MonthDayYear
Date

Consent For Use & Disclosure of Health Information & Acknowledgement of Receipt Of Notice of Privacy Practices
This form is optional under the new patient 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 address, social security numbers and demographic data) may be used in connection with your treatment, payment of your account or health care operations(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 to this Consent.

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

I have received a copy of this office’s Notice of Privacy Practices.
Patient’s Name
Patient or Guardian’s Signature

Clear
Print Name
Date

MonthDayYear
Date
Should be Empty:

GET ACQUAINTED QUESTIONNAIRE

INSURANCE VERIFICATION FORM

FAMILY INFORMATION

HEALTH INFORMATION

DENTAL HISTORY

Photo Release

Consent For Use & Disclosure of Health Information & Acknowledgement of Receipt Of Notice of Privacy Practices