Brettin Orthodontics - Patient Health History

Patient Health History
- Appointment Date
  
  MonthDayYear
  Appointment Date
- Name
  
  First NameLast Name
- Preferred Name
- SSN
- Date of Birth
  
  MonthDayYear
  Date
- Email
  example@example.com
- Age
- Gender
- Marital Status
- Patient Communications Contact Information
- How would you like to receive information?
- Primary Contact Name
  
  Primary Contact First NamePrimary Contact Last Name
- Primary Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Secondary Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Primary Email
  example@example.com
- Mailing Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Employment/Occupation/School (if applicable)
- Grade (if applicable)
- Name of Dentist
- Date of Last Visit
  
  MonthDayYear
  Date of last dental visit
- Related patients that are or have been under our care
- Name and date of birth of other children in the family
- Primary Parent/Legal Guardian
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
- Relationship to Patient
- Mailing Address (if different from patient's)
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Primary Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Secondary Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Employer
- Email
  example@example.com
- SSN
- Emergency Contact Name
  
  First NameLast Name
- Emergency Contact Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Marital Status
- May the patient's information be released to the secondary and/or additional parent or legal guardian in the next section of this form?
- Secondary Parent/Legal Guardian
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
- Relationship to Patient
- Mailing Address (if different from patient's)
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Primary Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Secondary Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Employer
- Email
  example@example.com
- SSN
- Additional Parent/Legal Guardian
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
- Relationship to Patient
- Mailing Address (if different from patient's)
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Primary Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Secondary Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Employer
- Email
  example@example.com
- SSN
- Please list other individuals who can receive patient information
- Name
  
  First NameLast Name
- Relationship to Patient
- Primary Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Name
  
  First NameLast Name
- Relationship to Patient
- Primary Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- How did you hear about us? (select all that apply)
  
  Other
- Primary Insurance Name
- Policyholder's name
  
  First NameLast Name
- Relationship to Patient
- SSN
- Date of Birth
  
  MonthDayYear
- Employer
- Subscriber/Member ID
- Group Number
- Provider Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Mailing Address for Claims
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Please check all that apply
  
  Other
- Please check if the patient has or has had
  
  Other
- List any allergies or serious illnesses
- Current drugs or medications
- Does patient need to be medicated before appointments?
- Reason
- Is patient presently under physicians care?
- Reason
- Name of primary care or other physician(s)
- If this consent is signed by a personal representative/parent on behalf of the individual, complete the following:
- Personal Representative's/Parent's Name
  
  First NameLast Name
- Relationship to Individual
- To the best of my knowledge, all the information is complete and correct. I give permission for any photographs, x-rays, or study models to be taken for diagnosis purposes. I agree to be responsible for charges not covered by my dental benefit plan. I, the undersigned agree to pay attorney fees and other fees imposed by a 3rd party collector in the event it becomes necessary to use attorney services to secure payment of this account.
- Signature
- We will not accept divorce decrees as assignments of responsibility for a minor’s orthodontic account. We require that the undersigned parent or legal guardian take full responsibility for all costs, and see reimbursement from other parties as needed.
- Should be Empty: