Child New Patient

Child New Patient
Patient Information
Patient Name

First NameLast Name
Preferred Name
Gender

MaleFemale
SSN #
DOB

MonthDayYear
Date
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School
Grade
Adopted?

YesNo
Siblings
Hobbies/Interests
Emergency Contact
Relationship to Patient
Phone Number
Please enter a valid phone number.
Guardian 1
Relationship to Patient:
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
DOB

MonthDayYear
Date
SSN #
Employer
Occupation
Parents’ Marital Status:

MarriedSingleDivorcedPartnered
Guardian 2
Relationship to Patient:
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
DOB

MonthDayYear
Date
SSN #
Employer
Occupation
Parents’ Marital Status:

MarriedSingleDivorcedPartnered
Financial Responsibility
Who is responsible for this account and relationship to patient?
Primary Dental Insurance
Primary Policyholder’s Full Name
DOB

MonthDayYear
Date
SSN#
Address and Phone (if not above)
Relationship to Patient
Employer
Address
Insurance Company
Group#
ID#
Insurance Company’s Phone
Orthodontic Coverage:

YesNo
I authorize release of any information regarding my child’s treatment to my dental insurance company.
Date

MonthDayYear
Date
Signature

Clear
Medical History
Is your child in good health?

YesNo
Child’s Physician
Last Seen
Phone
Any medical specialist(s) being seen now?

YesNo
Reason
Has patient reached puberty? (Girls: Monthly Cycle; Boys: Voice Change)

YesNo
Height
Weight
Has your child ever had a health problem?

YesNo
Has your child ever been hospitalized?

YesNo
Reasons and dates
Medicine or drug allergies?

YesNo
Allergies to

AcrylicNickelLatexOther
Other(Allergies)
Is your child taking any medications?

YesNo
Provide medication, dose and reason
Antibiotic premedication before dental visits?

YesNo
Please check the box if your child has been treated for any of the following:

Abnormal BleedingADD/ADHDAnemiaAny OperationsAsthma/BreathingAutismCancer/TumorsDiabetesEndocrine/GrowthFrequent InfectionsGI/GERDHearing/SpeechHeart Murmur/DiseaseHIV/AIDSKidney/LiverRheumatic FeverSensory/BehaviorSeizure(s)Tuberculosis (TB)Other
Other
Explain any checked boxes
Dental History
Dentist
Dentist Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last Seen
Reason
Any dental specialist(s) being seen now?

YesNo
Reason
How often does your child: Brush teeth?
Floss?
Please check the box if your child has been treated for any of the following:

Extra or missing teethChipped or injured teethGum diseaseHabits (thumb sucking, etc.)Speech concerns/therapyMouth breathing or snoringTongue thrustGrinding or clenching
Explain any checked boxes:
General Information
What concerns you or your child about his/her teeth?
How does your child feel about orthodontic treatment?
Does your child play a musical instrument?
Who may we thank for referring you to our office?
Previous orthodontic consultation?

YesNo
Previous orthodontic treatment?

YesNo
Have any other family members been treated in our office? Name(s)
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.
Date

MonthDayYear
Date
Parent/Guardian Signature

Clear
Consent for Disclosure of Protected Health Information (HIPAA)
SECTION A: Patient/Parent/Legal Guardian Giving Consent
Patient Name:
Date of Birth:

MonthDayYear
Date
SECTION B: Please read the following statements carefully:

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our notice accompanies this consent. We encourage you to read it carefully and completely before signing this consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain, and we will provide you with a copy of the revised Notice of Privacy Practices upon your request.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by requesting it from us.

Reopelle Orthodontics

2114 Colonial Avenue, SW Roanoke, VA 24015

(540)344-2758
Right to Revoke: You will have the right to revoke this consent at any time by giving us written notice of your revocation. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation, and that we will decline to treat you or to continue treating you if you revoke this consent. I, Type a label , have had full opportunity to read and consider the contents of this consent form and your Notice of Privacy Practices. I understand that, by signing this consent form, I am giving my consent to your use and disclosure of my protected health information or my child’s protected health information as described in the “Notice of Privacy Practices.”
Date

MonthDayYear
Date
Signature

Clear
Relationship to Patient:
Other person(s) to whom you give permission to discuss health information or bring child to routine care appointments:
Name:
Relationship to patient:
Should be Empty:

Child New Patient

Patient Information

Guardian 1

Guardian 2

Financial Responsibility

Primary Dental Insurance

Medical History

Dental History

General Information

Consent for Disclosure of Protected Health Information (HIPAA)

SECTION A: Patient/Parent/Legal Guardian Giving Consent

SECTION B: Please read the following statements carefully: