Patient Forms

PATIENT INFORMATION SHEET
Date

MonthDayYear
Date
Patient Name

First NameLast Name
Nickname
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (for reminder calls)
Please enter a valid phone number.
Email
example@example.com
Other Phone Numbers(Cell or Pager):
Please enter a valid phone number.
Birthdate

MonthDayYear
Date
Age
Sex
Race
School
Grade
Interests/Sports:
Musical Instruments Played:
Responsible Parties: (Primary denotes the person with the Primary Insurance Coverage)
Primary

MotherFatherStep ParentOther
If other, specify
SingleMarriedWidowedDivorcedOther
If other, specify
Name

First NameLast Name
DOB

MonthDayYear
Date
SS#
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Address
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Dental Insurance Carrier
Insurance Phone
Please enter a valid phone number.
Group Number
Member/Subscriber ID Number:
Drivers License Number:
Secondary

MotherFatherStep ParentOther
If other, specify
SingleMarriedWidowedDivorcedOther
If other, specify
Name

First NameLast Name
DOB

MonthDayYear
Date
SS#
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Address
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Other Responsible Parties:
Dentist
Last Cleaning Visit
Who may we thank for referring you to our once?
Please Check all relating to patients History
Medical

NoneAIDS/HIVAlcohol/Drug abuseAnemiaArtificial JointsArtificial ValveArthritisAsthmaAutoimmuneBleeding DisordersBone DisordersBulimiaCancerCerebral palsyChemotherapyChest painsCongenital DefectDiabetesDown SyndromeEndocrine problemsEmotional disordersEpilepsyFainting, DizzinessGlaucomaHandicap/DisabledHeadachesHearing ProblemsHeart conditionHepatitis/Liver ProblemsHigh Blood PressureHospitalizedImmune problemsJoint problemsKidney problemsLow Blood PressureMuscular disordersNeck pain-ChronicNervous DisordersOrgan TransplantOperationsPneumoniaPregnantProlonged BleedingRadiation TreatmentRheumatic FeverScoliosisSeizures/ConvulsionsSinus ProblemsStrokeTuberculosisVenereal DiseaseADHD
Allergies

NoneDrugsLatexMetalsPlasticsRubberSeasonalSinus Issues
Dental

NoneClicking of jawCold Sores/HerpesPainful chewingPeriodontal problemsSpeech problemsTMJ problemsTooth GrindingUnfinished Dental work
Please explain any circled items above:
Any other disease, problems or allergies not listed above?
Current medications:
Female: Has she started menstruating?

YesNo
When?
Wisdom teeth extracted?

YesNo
Any face or mouth injuries?

YesNo
Any missing teeth?

YesNo
Normally breath through the mouth while awake or sleeping?

YesNo
Do gums bleed when brushing or flossing?

YesNo
Previous orthodontic treatment?

YesNo
Have other orthodontists been consulted?

YesNo
Are there any mouth habits past or present(thumb or finger sucking, pacifier, mouth breathing, etc.)?

YesNo
Have tonsils and adenoids been removed?

YesNo
Other concerns?
Names and ages of brothers and sisters?
Would you like us to see anybody else in the family?
The undersigned hereby authorizes Dr. Ragan and/ or his staff to perform the examination including x-rays, photo’s and study models. I authorize the discussion and/ or consultation of the provided information, examination and records with dentists, dental specialists, and other health care professionals as needed. Orthodontic appliances are composed of very small parts that could be accidentally swallowed, aspirated (inhaled), impacted and could irritate or damage the oral tissues. If unsure of the location or the object is inhaled or ingested, a chest x-ray may be required to isolate the object. The undersigned authorizes all forms of treatment including separators, bands and braces with knowledge and understanding of the risks. This shall remain in force and effective until cancelled by either party. All fee’s for services rendered are due at the conclusion of each
appointment, unless other financial arrangements have been made.
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Pediatric Sleep Questionnaire: Sleep-Disordered Breathing Subscale

Please answer these questions regarding the behavior of your child during sleep and wakefulness. The questions apply to how your child acts in general during the past month. You should circle the correct response. A “Y” means “yes,” “N” means “no,” and “DK” means “don’t know.”
Child's Name

First NameLast Name
Person Completing the Form
Date

MonthDayYear
Date

WHILE SLEEPING, DOES YOUR CHILD:

	Y	N	DK
Snore more than half the time?
Always snore?
Snore loudly?
Have “heavy” or loud breathing?
Have trouble breathing, or struggle to breathe?

HAVE YOU EVER SEEN YOUR CHILD STOP BREATHING DURINGTHE NIGHT?

YNDK

DOES YOUR CHILD:

	Y	N	DK
Tend to breathe through the mouth during the day?
Have a dry mouth on waking up in the morning?
Occasionally wet the bed?
Wake up feeling unrefreshed in the morning?
Have a problem with sleepiness during the day?

HAS A TEACHER OR OTHER SUPERVISOR COMMENTED THAT YOUR CHILD APPEARS SLEEPY DURING THE DAY?

YNDK
IS IT HARD TO WAKE YOUR CHILD UP IN THE MORNING?

YNDK
DOES YOUR CHILD WAKE UP WITH HEADACHES IN THE MORNING?

YNDK
DID YOUR CHILD STOP GROWING AT A NORMAL RATE ATANY TIME SINCE BIRTH?

YNDK
IS YOUR CHILD OVERWEIGHT?

YNDK

THIS CHILD OFTEN:

	Y	N	DK
Does not seem to listen when spoken to directly.
Has difficulty organizing tasks and activities.
Is easily distracted by extraneous stimuli.
Fidgets with hands or feet or squirms in seat.
Is “on the go” or often acts as if “driven by a motor”.
Interrupts or intrudes on others (eg., butts into conversations or games).

Orthodontic Appointment Policy

We do our very best to see every patient on time, to have you in and out as quickly as possible and appreciate the same courtesy on your part. This policy is our way of sticking to our goal and we ask for your cooperation with the following
Please check each section of the following to acknowledge understanding.

Appointment Times: We strive to schedule as many before and after school/work andlunch time appointments for you as possible. It will be necessary to schedule someappointments during school or work hours due to the length and complexity of theprocedure.Appointment intervals: Range from 2 to 10 weeks between visits with most appointmentsbeing 6 to 8 weeks apart. We do provide excuse slips for any missed classes or work.Punctuality: If you are running late please call us and let us know ahead of time, as toaccommodate you if possible. If you are more than 15 minutes late for an appointment,we may have to reschedule the appointment as a courtesy to our other scheduledpatients.Canceled, Missed, or Rescheduled Appointments: Canceling or changing an appointment less than 24 hours prior to the scheduled appointment could result in a cancelation or change fee charged to your account. A missed appointment may also result in a fee charged to your account. If you cancel an early morning or afterschool appointment, it could be a month or more before another similar time is available. Please keep in mind that missed, cancelled, or changed appointments could delay treatment progress significantly.Scheduling Appointments: As a courtesy we call/text/email before your scheduledappointment. We suggest that you schedule your next appointment before you leave theoffice to obtain the most ideal time for your needs. We do not always have the time to callyou to schedule your appointment and when we do it is as a courtesy to you. If you miss ordo not schedule an appointment, it is your responsibility to call or come in and make thenew appointment.
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Date

MonthDayYear
Date
Date

MonthDayYear
Date
Print Name
Relationship to patient
PRIVACY CONSENT

This form is optional under the new patient privacy regulations recently issued by the United States Department of Health and Human Services. We have elected to use this form. Prior to commencing you or your child’s orthodontic treatment, you should review, sign and date this form.

You or your child’s protected health information or PHI (i.e., individually identifiable information such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used in connection with you or your child’s treatment, payment of your account or health care operations (i.e., performance reviews, certification, accreditation and licensure).

You have the right to review our office's Privacy Notice prior to signing this Consent, a copy of which was given to you with this Consent. In signing this consent you agree to the content of the Privacy Notice.

You have the right to request restrictions on the use of you or your child’s protected health information. However, we are not required to, and may not, honor your request.

We may amend the attached privacy notice at any time. If we do, we will provide you with a copy of the changes, and the changes may not be implemented prior to the effective date of the revised notice.

You may revoke this Consent at any time in writing. However, such revocation will not be effective to the extent that any action has been taken in reliance on this Consent.

Thank you for your cooperation. Please let us know if you have any questions.
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Patient Name

First NameLast Name
Date

MonthDayYear
Date
PRIVACY AUTHORIZATION

This Authorization is required by the privacy regulations recently promulgated by the United States Department of Health and Human Services.
You or your child’s protected health information, including photographs, x-rays, study models can be used or disclosed for the purpose of:

Lectures/presentationsPublicationsResearch and orPractice Marketing
The information will be disclosed on an as needed basis by our office.

You have the right to revoke this Authorization at any time in writing. However, your revocation will not be effective to the extent that this Authorization has been relied on.

The information used or disclosed per this Authorization may be subject to re-disclosure by the recipient(s), and thus, no longer protected by the privacy rules.
Patient Name

First NameLast Name
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Date

MonthDayYear
Date
Should be Empty:

PATIENT INFORMATION SHEET

Responsible Parties: (Primary denotes the person with the Primary Insurance Coverage)

Pediatric Sleep Questionnaire: Sleep-Disordered Breathing Subscale

Orthodontic Appointment Policy

PRIVACY CONSENT

PRIVACY AUTHORIZATION