Welcome To Freeman Orthodontics - Health History Form

Date*

Date

Patient's Name*

First NameMiddle NameLast Name

Patient's Date of Birth*

Date

Patient's Social Security Number*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Please enter a valid phone number.

Email Address*

example@example.com

Please click all of the ways you heard about our office*

	Referral Sources
Dentist
Google
Instagram
FaceBook
Fort Lauderdale Magazine Voted Best Orthodontist Article
Other Magazine
Friend
School

If referred by a friend, whom may we thank for referring you to our office?

	Yes	No
Is The Patient A Minor?

What school do they attend?*

	Patient	Other
Who Is The Responsible Party?

Please provide the Responsible Party's Name*

First NameMiddle NameLast Name

Responsible Party's Relationship To The Patient*

Responsible Party's Phone Number*

Please enter a valid phone number.

Responsible Party's Address (fill in if different than patient)

Street Address

Street Address Line 2

CityState

Postal / Zip Code

Responsible Party's Date Of Birth*

Responsible Party's Social Security Number*

Responsible Party's Picture of Drivers License*

Drivers License Number*

Other Parents Or Guardians Name

Their relationship to patient

Other Parent Or Guardian's Phone Number

	Yes	No
Does The Patient Have Dental Insurance?

Please take a picture of the Front of your Insurance Card*

Please take a picture of the Back of your Insurance Card*

Insured's Name*

Insured's Employer Name If Insured Through Work (If private insurance type, N/A)*

Insured's Social Security #*

Insurance Company Name*

Insurance Company Address*

Insurance Company Phone Number*

Insurance Group Number*

Insurance Member Number*

	Yes	No
Does The Patient Have Dual Coverage? (2 Dental Insurance Plans)

Please take a picture of the Front of your Insurance Card*

Please take a picture of the Back of your Insurance Card*

Insured's Name (The Card Holder's Name)*

Insured's Company / Employer Name If Insured Through Work (If private insurance type, N/A)*

Insured's Social Security #*

Insurance Company Name*

Insurance Company Address*

Insurance Company Phone Number*

Insurance Group Number*

Insurance Member Number*

Physician Name

Physician's Phone Number

	Yes	No
Is The Patient Currently Taking Any Medications?

Please list any medications currently being taken*

	Yes	No
Does the Patient have any allergies? (especially to Latex)

Please list any allergies (especially to latex)*

Please list any major illnesses you have or previously had.*

If you ever had an accident to your face or mouth, please describe.

If you ever had any major operations, please describe.

Have you ever had, or do you currently have, any of the following medical conditions?*

	Yes	No
Abnormal bleeding / Hemophilia
Anemia
Arthritis
Asthma
Bone Disorders
Congenital Heart Disease
Diabetes
Dizziness
Epilepsy
Gastrointestinal Disorders
Heart Problems
Heart Murmur
Hepatitis / Liver Disorders
Herpes
High Blood Pressure
HIV / AIDS
Kidney Problems
Nervous Disorders
Prolonged Bleeding
Radiation / Chemotherapy
Rheumatic Fever
Tuberculosis (TB)
Tumor / Cancer

General Dentist (If you do not have one type, NONE)*

Estimated Date of Last Dental Cleaning Visit*

What concerns you about your teeth? Click all that apply.

	Please Evaluate For
Spacing
Crowding
TMJ Problems
Bite Is Off
Early Interceptive Orthodontics
My Dentist Referred Me to Dr. Freemanto set up alignment in preparation for Restorations (Veneers, Crowns, Implant, Bridge or Oral Surgery)

	Yes	No
Are you presently in dental pain?
Have you experienced any unfavorable reaction to dentistry?
Have you ever lost or chipped any teeth?
Have you had any injuries to the face, mouth or teeth?
Is any part of your mouth sensitive to pressure?
Do your teeth or jaws feel uncomfortable in the morning?
Does your jaw click or pop?
Do you clench your teeth?
Do you grind your teeth?
Has anyone in your family received orthodontic treatment?
Are you aware some appointments will be during school / work hours?
Are you pregnant?

What is important to you?

	1 - Extremely	2 - Very	3 - Important	4 - Somewhat	5 - Not
Length of Treatment
Comfort
Clear / Invisible
Low Down Payment
Low Monthly Payment
Quality Of Treatment
Interested In Starting ASAP

Benefits of orthodontics: Aesthetic, Health and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in general function of the teeth and in general dental health. Teeth, gums and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced. tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also understand that my or my childs diagnostic records and name may be used for educational and promotional purposes in media. Your calls to our office may be recorded for training purposes. I have truthfully answered all of the above questions and agree to inform this office of any changes of personal information, medical or dental history. In addition, I authorize Dr. Freeman and his staff to perform a complete orthodontic evaluation and necessary services. I understand that where appropriate, credit bureau report may be obtained.

Signature

Todays Date

HIPAA Compliance Patient Consent Form
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.
The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.
The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.
You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.
By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.
By signing this form, I understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
All calls are recorded for customer service and training purposes.
The practice reserves the right to change the privacy policy as allowed by law.
The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
The practice may condition receipt of treatment upon execution of this consent.

	Yes	No
May we call, email or text you to confirm appointments?
May we leave a message on your voicemail?
May we discuss your medical condition with family members

Signature

Date

Welcome to Freeman Orthodontics!