10-2024 SAO New Patient Forms

Confidential Patient Information
Thank you for filling out our online new patient paperwork! If using insurance, you will need the insured party's insurance information (SSN, insurance company name, insurance ID# and group#) to complete the form. Please bring a copy of your photo ID and insurance card to the appointment.
Which location will you be visiting?*
Patient's Name:*

First NameLast Name
Best Contact Phone:*
Please enter a valid phone number.
Best Contact Email:*
example@example.com
Patient's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Date of Birth:*

MonthDayYear
Date
Patient's SSN:*
Gender*

MaleFemale
Is the patient a minor?

YesNo
Is the patient the financially responsible party?*

YesNo
Please list the financially responsible party:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail Address:*
Cell Phone:*
Home Phone:
Social Security #:*
Date of Birth:*

MonthDayYear
Date
Relationship to Patient:*
Employer:*
Who may we thank for referring you to our office?*

Parent/Guardian 1
Is Parent/Guardian 1 the financially responsible party?

YesNo
Name:*

First NameLast Name
Marital Status:
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail Address:*
Cell Phone:*
Home Phone:
Social Security #:*
Date of Birth:*

MonthDayYear
Date
Relationship to Patient:*
Employer:*
Occupation:
Parent/Guardian 2
Is there a Parent/Guardian 2?

YesNo
Is Parent/Guardian 2 the financially responsible party?

YesNo
Name:*

First NameLast Name
Marital Status:
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail Address:*
Cell Phone:*
Social Security #:*
Date of Birth:*

MonthDayYear
Relationship to Patient:*
Employer:*

Insurance Information
Will you be using insurance?

YesNo
Policy Holder's Name:*

First NameLast Name
Policy Holder's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate:*

MonthDayYear
Policy Holder's Social Security #:*
Employer:*
Insurance Company:*
ID #:*
Group #:*
Is there a secondary insurance?*

YesNo
Policy Holder's Name:*

First NameLast Name
Policy Holder's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate:*

MonthDayYear
Policy Holder's Social Security #:*
Employer:*
Insurance Company:*
ID #:*
Group #:*

Emergency Information
Emergency Contact:*

First NameLast Name
Phone Number:*
Email:*
Relationship to Patient:*
Signature (Parent's signature if minor):*

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HIPAA
I understand that, under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan, and direct my treatment and follow-up among the multiple health care providers who may be involved in that treatment directly and indirectly.
- Obtain payment from third-party payers.
- Conduct normal health care operations such as quality assessments and physician certification.
I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, obtain payment, and conduct normal health care operations. I also understand you are not required to agree to my requested restriction, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

By signing this form, you consent to our use and disclosure of your protected healthcare information as outlined in this form. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.
May we phone/text/email you regarding your appointment?*

YesNo
May we send e-statements in regards to your account?*

YesNo
May we leave a message on your answering machine or voicemail?*

YesNo
May we discuss your medical condition with any member of your family?*

YesNo
If YES, please name the members allowed:
I,(print name)* have received a copy of this office's Notice of Privacy Practices.
Signature (Parent's signature if minor):*

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Date:*

MonthDayYear
Date

NOTICE OF FILMING & PHOTOGRAPHY
Patient Name:*

First NameLast Name
When you enter San Antonio Orthodontics (SAO) you are entering an area where photography, audio, and video recording may occur.

By entering the premises, you acknowledge that photography, audio recording, video recording may occur, and may be used in publication, exhibition, or reproduction for news, webcasts, promotional purposes, telecasts, advertising, inclusion on websites, social media, or any other purpose by SAO and its affiliates and representatives. Images, photos and/or videos may be used to promote SAO in the future, and exhibit the capabilities of SAO. You release SAO, its officers and employees, and each and all persons involved from any liability connected with the taking, recording, digitizing, or publication and use of interviews, photographs, computer images, video and/or sound recordings. It will always be our intention to obtain specific consent from those present prior to any such activity.

By entering the San Antonio Orthodontics (SAO) premises, you waive all rights you may have to any claims for payment or royalties in connection with any use, exhibition, streaming, webcasting, televising, or other publication of these materials, regardless of the purpose or sponsoring of such use, exhibiting, broadcasting, webcasting, or other publication irrespective of whether a fee for admission or sponsorship is charged.

You also waive any right to inspect or approve any photo, video, or audio recording taken by SAO or the person or entity designated to do so by SAO. You have been fully informed of your consent, waiver of liability, and release before entering the premises.
Signature (parent/guardian if patient is a minor):*

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Date:*

MonthDayYear
Date
Should be Empty:

Confidential Patient Information

Parent/Guardian 1

Parent/Guardian 2

Insurance Information

Emergency Information

Dental History

Medical History

HIPAA

NOTICE OF FILMING & PHOTOGRAPHY