New Ortho Patient Registration Form

New Ortho Patient Registration Form
Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
Date
Preferred Nickname
Legal Gender*
Patient Age*
The Patient is...*

Is already scheduled for an upcoming consult with McNutt OrthodonticsIs not yet scheduled and I will be contacting the practice to schedule soon
For children & college students, the patient’s current schooling is (skip if not applicable):

PublicPrivateHomeschoolUniversity/College
Name of School Patient Attends
Name of Adult Contact #1 (adult patients enter your own name and information)*

First NameLast Name
Relationship to Patient*
Mobile Phone Number for Adult Contact #1*
Please enter a valid phone number.
Email Address for Adult Contact #1*
example@example.com
Address for Adult Contact #1*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Adult Contact #2 (adult patients enter your own name and information)

First NameLast Name
Relationship to Patient
Mobile Phone Number for Adult Contact #2
Please enter a valid phone number.
Email Address for Adult Contact #2
example@example.com
Address for Adult Contact #2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List any other adults or family members (step parents, siblings, spouse, significant other) that we are permitted to work with during treatment.
Is there a custodial agreement that requires mutual consent for treatment?*

YesNo
Enter the name(s) of all who will be financially responsible for the patient*
Are there family members who have already been seen by us?*

YesNo
Dental Insurance
In order to provide you with an accurate treatment cost and monthly payment plan for orthodontic treatment, we require verifying orthodontic insurance coverage. We are not in the network with NC Medicaid for orthodontic treatment.

Please enter the information for the PRIMARY policy below. In the event there is secondary insurance, we ask that you email us that information in advance as well. If you are uncertain about which policy is primary and which is secondary, enter one policy below and email us the other policy. Emailing a photograph of the front and back of the insurance cards is very helpful.

Email us at: referral@thetoothmover.com.

In the subject line please write: INSURANCE / PATIENT NAME / DOB.
Does the patient have orthodontic insurance coverage?*

YesNoUnsure
Please enter the information for the policy below:
Subscriber Name

First NameLast Name
Subscriber DOB

MonthDayYear
Date
Subscriber Address If Different From Patient

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber ID
Subscriber SSN
Group #
Insurance Company
Provider Phone Number
Please enter a valid phone number.
Employer
Current Dentist Information
Enter the name of patient’s family dentist (enter “none” if there is no current dentist)*
We are required to verify that the patient is up to date with his / her dental exam and dental cleaning with the family dentist.

Patients who are significantly over-due or do not have a current dentist are not eligible for active orthodontic treatment.

Patients who are more than 12 months overdue should see their family dentist before scheduling an orthodontic examination. In most circumstances, we are not permitted to begin orthodontic treatment if the patient has dental work that still needs to be completed.

In the event that the last dental exam and cleaning was more than a year ago, delaying the orthodontic exam until after the patient has seen the dentist is generally wise. In the event the patient does not have a local family dentist, we are glad to help refer you to a local practice.
The patient had a dental exam and cleaning...*
To the best of your knowledge...*
Type Of Examination / Consultation Interested In (Check all that apply):*

Orthodontic Exam & Treatment ConsultationRe-Treatment After Orthodontics (Teeth have shifted)Replacement or Repair of RetainersReplacement or Repair of Night GuardTMJ/TMD Examination & Treatment OptionsOrthodontics With Jaw Surgery Consult
Is there a history of trauma to primary / baby teeth? (If yes please provide details).*
Is there a history of trauma to permanent adult teeth? (If yes please provide details).*
Has the patient experienced injury to the face or jaws? (If yes please provide details).*
Has the patient had jaw / orthognathic surgery in the past? (If yes please provide details).*
Does the patient have anxiety about dental appointment appointments? (If yes please provide details).*
The patient has been evaluated by an orthodontist in the past.

YesNo
Below are the most commonly used ways we align teeth for patients. Check all that the patient would consider or is interested in:*

Traditional Braces With Colors (Metal Stainless Steel)Traditional Braces (Rose Gold Finished Metal)Self-Ligating BracesClear Aligners, Such as Spark or ULABPrefer Option Doctor Believes is BestUncertainOther
Please Check All Concerns Below That Relate To The Patient:*

Replace or Repair Retainer(s)Seeking a Second/Other OpinionResolving TMJ/TMD Jaw IssuesMissing Permanent Adult TeethImprovement of the SmileUnderbiteOverbiteNarrow Palate/Upper JawPoor Bite RelationshipProtrusion of the TeethConcerned that Front Teeth Are at Risk for TraumaLips Will Not Close Over Teeth ProperlyTeeth Emerging in Wrong SpotsAligning the Teeth Prior to Dentist/Oral Surgeon Replacing Missing/Bad Teeth With Implants or Dental BridgesCross-Bite of Front TeethCross-Bite of Back TeethCrowding of the TeethSpaces Between the TeethTeeth Are Wearing Down ExcessivelyImpacted Teeth That Are Stuck in the Jaw BoneExtra Adult Teeth Have DevelopedThumb or Finger Sucking HabitTongue Thrusting HabitProblems With Breathing or Sleep Related to ApneaConcerns About the ProfileThe Face/Jaws Appear AsymmetricI Have Been Told the Patient May Require Jaw SurgeryNone of the above
Please list any additional concerns or information that our team should know
General Medical History
Is the patient in good health?*

YesNo
Bisphosphonates: Is there a history of taking Bisphosphonate drugs (ex. Fosamax) for treatment of osteoporosis or other bone disorders? (If yes please provide details).*

YesNoUnsure
Current Regular Prescription Medications If none, write “none” in comment box.*
Is The Patient Allergic To Or Had Any Unusual Reactions To Any Of The Following (select all that apply):*

LatexPenicillinRed DyeSulfa DrugsTree NutsDairyFood AllergiesOtherNone
Please list any other allergies we should be aware of
Are antibiotics required prior to invasive dental procedures? (If yes please provide details).*
Does the patient have any ongoing oral habits? Examples are: sucking a finger / thumb / pacifier / on a blanket / grinding / tongue thrust*

YesNoUnsure
If yes please select all that apply

PacifierThumb/Finger SuckingTongue ThrustJaw ClenchingTeeth GrindingSucking on a BlanketOther
Does the patient regularly or occasionally do any of the following? Check all that apply:*

VapeSmokeless Tobacco/ChewSmoke CigarettesDrink Soda/Carbonated BeveragesNone/Not Applicable
Health Conditions Checklist
If the patient has a history of any of the following health conditions check the box next to the condition.*

AIDS/HIVADD or ADHDAnxiety Related to Dental ProceduresAsthma/Reactive Airway DiseaseAutism/Autistic SpectrumAutoimmune DisorderBipolarBleeding DisorderCancerCerebral PalsyCleft Lip/PalateCongenital Birth DefectsDepressionDevelopmental Disorder/Learning ProblemsDiabetes/Hyperglycemia/HypoglycemiaGERD or Acid RefluxHearing ImpairmentHeart ComplicationsHigh Blood PressureHormone/Endocrine DisordersPhysical Developmental DelaySeizures/EpilepsyNone of the Above
Any additional medical history comments or conditions:
Who may we thank for referring you to our practice? Check all that apply:

Current Family DentistPediatricianHygienist/Assistant/Dental Team MemberExisting Family MemberWord of Mouth in CommunitySocial MediaOnline Mom's GroupInternet Search EngineNone
Is there someone specific we may send a thank you to?
Optional: You may upload images such as X-rays, a copy of the front and back of your dental insurance card, & any previous dental chart notes.

Cancelof
Review & Acknowledgement of Practice Policies
NEW PATIENT CONSULT APPOINTMENT CANCELLATION & RESCHEDULING POLICY

To cancel your appointment, please notify our office at least twenty-four (24) hours in advance of your scheduled appointment time. Appointment changes can only be accepted during regular office hours. Less than twenty-four hours advanced notice during regular business hours is considered a missed / no-show appointment. Rescheduling a consultation appointment may incur a fee that is collected prior to rescheduling.

PRIVACY DISCLOSURE STATEMENT & ACKNOWLEDGEMENT

This section is optional under the new patient privacy regulations recently issued by the United States Department of Health and Human Services. It discloses to you how we normally operate and your acknowledgment thereof. The digital signature at the conclusion of this form does hereby signify that the undersigned does hereby attest to having been afforded the opportunity to review the Matthew David McNutt, DDS, MS, PA notice of privacy policy noted below. Patients / Parents / Guardians have the right to review our notice of privacy policy prior to signing this consent. You have the right to request restrictions on the use of your protected health information. We value protecting private patient information and have implemented layers of protection and staff training. This disclosure does serve as notice that: Full initial examinations generally occur in a private consultation room. It is customary for patients upon arrival to use our digital check-in device (iPad) to signify their arrival for a scheduled appointment, and this device displays the legal name of the patient. Our orthodontic treatment facilities operate with an ‘open-bay’ concept in the main clinic (no partitions or physical visual barriers between patient treatment chairs). This creates a fun and welcoming environment. Patients, their family members, and the staff will be present. Despite our best efforts to operate in a respectful and discrete manner, it is not possible within the practice to guarantee full privacy of all protected health information. A copy of the full privacy disclosure statement is available on our website and in the office.

POLICIES REGARDING FINANCIAL ARRANGEMENTS & INSURANCE BENEFITS

Our practice has established Policies Regarding Financial Arrangements & Insurance Benefits for patient care provided by Matthew David McNutt, DDS, MS, PA. A copy of this document is available on our website and in the office. The digital signature at the conclusion of this form does hereby signify that the undersigned has been informed of this and will be afforded the opportunity to review these policies prior to pursuing treatment with our practice.

NEW PATIENT EXAMINATION EXPECTATIONS & FEES: Most of our new patient examinations are at no charge and others do incur a fee. This will vary depending on the type of exam and the circumstances. After reviewing the completed registration packet, our treatment coordinator will contact you in advance to discuss any examination fees prior to the scheduled consultation. The number of exams we schedule each day is considerably less than most orthodontic practices and is limited to 4-5. This is one reason for our careful screening process. We also limit the time of day we are willing to schedule new patient examinations. We realize that other offices may offer more convenient times as well. However, we understand that it is nearly impossible for an orthodontist to spend 20-30 minutes of quality time with 8-12 new patients a day, and still be hands-on with patients who are actively in treatment in the clinic. During the highly desirable early morning and after school hours Dr. McNutt is hands-on with his team, instead of delegating everything in order to see more new patient exams.

RELEASE FORM FOR MEDIA USE
We are passionate about creating a lifetime of healthy teeth and beautiful smiles. One of the best ways to share our enthusiasm and educate people is to share images of our team having fun with patients in the office and to share our work. We want to create positive and reassuring examples of good oral health within the community. We often do this by sharing content we have created in the office, on our website and on social media. Images/videos of patients may be a part of that media. We treat the privilege of sharing our work with great respect.
Please select all of your preferences / permissions that apply below:*

I hereby grant permission to use patient images and media obtained as described above to promote the practice and to promote good oral health within the community.I also grant permission for our family to be 'tagged' on social media in conjunction with our postsI DO NOT grant permission to use patient images and media obtained as described above.
Please understand that you have the right to revoke permission or grant permission in the future as you see fit.

AUTHORISATION & DIGITAL SIGNATURE CONSENT FOR NEW PATIENT EXAMINATION
The digital signature of the undersigned at the conclusion of this form does hereby grant and convey:
- Consent to allow Dr. Matthew David McNutt, DDS, MS, PA to conduct an orthodontic examination of the aforementioned patient.
- Understanding the examination will include diagnostic photographs (teeth and facial features).
- Understanding that in order to complete at full exam we will usually need to evaluate a recent panoramic radiograph.
- Consent to obtain a copy of the most recent panoramic radiograph (X-ray) from your family dentist.
- Consent as necessary to obtain a new panoramic radiograph in our office the day of the examination, unless specifically prohibited by you at the exam, as is your right.
- Understanding that in the event that permission to obtain diagnostic radiographs / X-rays is denied prior to, during and after treatment, the undersigned does hereby release the practice, practice ownership and doctor(s) from any responsibility related to the consequences of oral conditions possibly present that are not fully revealed or are undiagnosed as a result of opting out of dental radiographs.
- Understanding that treatment options and estimated treatment fees may be discussed.
CONSENT TO RELEASE RECORDS & CORRESPOND WITH OTHER DOCTORS:
The digital signature at the conclusion of this form does hereby grant and convey permission to:
- Release records to and correspond with the patient’s dentist of record.
- Release records to and correspond with specialists for procedures related to the patient’s recommended treatment plan.
Furthermore, the undersigned does hereby attest to:
- Having read, understood, and completed this registration packet accurately.
- Understands and agrees to abide by the policies herein.
- Grants or denies permissions as selected herein.
- Furthermore, the undersigned is responsible for informing our practice of any changes to the patient’s contact information, changes in insurance and changes to medical status / history.
- Having the authority to sign below.
RADIOGRAPH / X-RAY ACKNOWLEDGMENT & PERMISSIONS
Radiograph / X-Ray Acknowledgment & Permissions Radiographs (X-Rays) are likely to be recommended at your child’s dental exam. Please read both statements below and select an answer option:

Statement # 1: In the event that new dental X-rays are recommended by the doctor, I understand that I will be notified in advance prior to any X-rays being taken. I understand that not all X-rays may be covered by my dental insurance. I understand that I am responsible for all fees if my insurance company does not cover all or a portion of the X-rays.

Statement # 2: I DO NOT grant permission for dental X-rays to be taken at the initial exam and I will discuss my concerns with the doctor. I understand that there are numerous dental diseases and pathology that cannot be diagnosed without the use of dental X-rays. I hereby release the practice, practice ownership and doctor(s) from any responsibility related to the consequences of oral or systemic health conditions possibly present that are not fully diagnosed or remain undiagnosed as a result of opting out of dental radiographs.
I have read statements 1 & 2 and grant permission for X-raysI have read statements 1 & 2 and DO NOT grant permission for X-rays
Your Signature*

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New Ortho Patient Registration Form

Dental Insurance

Current Dentist Information

General Medical History

Health Conditions Checklist

Review & Acknowledgement of Practice Policies