PICKETT ORTHODONTICS PATIENT INFORMATION FORMS
PATIENT:
First Name
Middle Name
Last Name
DOB:
-
Month
-
Day
Year
Date
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SSN:
Home Phone:
Please enter a valid phone number.
Cell Phone:
Please enter a valid phone number.
Email:
example@example.com
Gender:
Marital Status:
School:
Grade:
Previous Family Members:
Other Siblings (name/age):
Primary Guardian
Name:
First Name
Last Name
SSN:
DOB:
-
Month
-
Day
Year
Date
Relation to Patient:
Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Number:
Please enter a valid phone number.
Cell Number:
Please enter a valid phone number.
Work Number:
Please enter a valid phone number.
Email:
example@example.com
Employer:
Position:
Years Employed:
Spouse's Name:
First Name
Last Name
Spouse's Employer:
Spouse's Number:
Please enter a valid phone number.
Secondary Guardian
Name:
First Name
Last NameLast Name
SSN:
DOB:
-
Month
-
Day
Year
Date
Relation to Patient:
Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Number:
Please enter a valid phone number.
Cell Number:
Please enter a valid phone number.
Work Number:
Please enter a valid phone number.
Email:
example@example.com
Employer:
Position:
Years Employed:
Spouse's Name:
First Name
Last Name
Spouse's Employer:
Spouse's Number:
Please enter a valid phone number.
INSURANCE
Primary:
Contract #:
Group #:
Insurance Phone:
Please enter a valid phone number.
Employer:
Subscriber:
Relation to Patient:
DOB:
-
Month
-
Day
Year
Date
SSN:
Secondary:
Contract #:
Group #:
Insurance Phone:
Please enter a valid phone number.
Employer:
Subscriber:
Relation to Patient:
DOB:
-
Month
-
Day
Year
Date
SSN:
Referral
Dentist:
Last Cleaning:
Did They Refer?:
Dentist Concerns:
Other Referral Source:
Concerns/History
Has patient had previous orthodontic consult? If so, please explain:
Patient/Family's Dental/Orthodontic Concerns:
Interested In (ex: Braces, Invisalign, Retainers, etc.):
Dental Conditions:
Explain Dental Conditions:
Is patient under a physician's care? If so, please explain:
Medical Conditions:
Explain Medical Conditions:
Please List Current Medications:
Allergies:
Social Media
It is important to Pickett Orthodontics, LLC to utilize social media to share our highlights of our daily routine and exciting events and transformations that take place at our office. When doing this, images of patients are sometimes included. However, we never want a patient or family to feel uncomfortable and want to give you the option to participate. Please let us know if you consent to the inclusion of the patient in our pictures of our office and/or social media posts. Do you authorize Pickett Orthodontics, LLC to include the patient in in office - related social mediate posts regarding treatment milestones, contests, etc.?
Signature:
Date:
-
Month
-
Day
Year
Date
COVID-19 NOTICE AND ACKNOWLEDGEMENT
Our goal is to provide a safe environment for our patients and staff, and to advance the safety of our local community. This document provides information we ask you to acknowledge and understand regarding the COVID‐19 virus. The COVID‐19 virus is a serious and highly contagious disease. You could contract it from a variety of sources. Our practice wants to ensure that you are aware of the additional risks of contracting COVID‐19 while receiving dental care. Dental health care providers have a long history of experience with, and knowledge of, preventing the spread of contagious diseases. However, the COVID‐19 virus has a long incubation period. You or your healthcare providers may have it and not show symptoms and yet still be contagious. Determining who is currently infected by COVID‐19 is challenging because of limitedavailability of testing. Due to the frequency and timing of visits by other patients, the characteristics of the virus, and the characteristics of dental procedures, there is a risk of your contracting the virus by being in a dental office. Of course, you could contract the virus outside the dental office, unrelated to your dental visit. Please confirm that you have read this Notice and understand and accept that there is a risk of contracting the COVID‐19 virus in a dental office or with dental treatment.
Signature:
Date:
-
Month
-
Day
Year
Date
Acknowledgement Of Receipt of Privacy Practices (A copy of this document may be found below)
Signature:
Date:
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: