New Patient Information Form

New Patient Information Form

Section 1
Today's Date

MonthDayYear
Date
Name of person completing the form:
Relationship to Patient:

Other
Patient Name:

First NameMiddle NameLast Name
Patient Date of Birth:
Patient Preferred Name:
Patient Gender:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number:

Area CodePhone Number
Patient's Phone Number if 16 or older:

Area CodePhone Number
How did you hear about our practice?
Were you referred by a dentist?
If yes, by whom?
Please list the names of any immediate family members that have been seen at our practice:
Patient's School:
Please list any sports or hobbies enjoyed by the patient:
Patient Medical History

Section 2
Current Physician (name and number)
Please list all prescription and over the counter medications including name, dosage, purpose and time of day taken. If none, please note N/A:
Please indicate if the patient has any of the following allergies:

Other
Please indicate whether the patient has had any of the following:

Other
If yes to any, list dates, kinds, controlled or uncontrolled
Does the patient smoke/chew tobacco?
Patient Dental History

Section 3
Current Dentist:
Date of last dental cleaning:
Any pending dental work?
If yes, please describe:
Has a physician or dentist recommended taking antibiotics prior to dental treatment?
Any complications from dental treatment?
If yes, please describe:

Please indicate if the patient has experienced any of the following:

Rows	Past	Present	Never
Clench/grind teeth
Bite cheek(s)
Tongue thrust
Mouth breathing
Nail Biting
Suck thumb/finger
Jaw clicking/popping
Sensitive to hot/cold
Chipped/lost teeth

If present or past to any above, please describe.
Experiencing any mouth pain?
If yes, where at, what type and for how long?
Frequency of brushing:

Other
Frequency of flossing:

Other

Please indicate if the patient has experienced any of the following:

Rows	Past	Present	Never
Orthodontic Treatment
Bite plate/ guard
Periodontic Treatment
Oral Surgery
Serious injury to mouth or head

If present or past to any, please list what, dates, and reasons.
What is the reason for seeking an orthodontic evaluation?
How does the patient feel about orthodontic treatment?

Responsible Party Information

Section 4
Responsible Party

Other
Responsible Party Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Social Security #
Occupation:
Additional Parent/Guardian (please complete if applicable):

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Social Security #
Occupation:

Responsible Party Policy

Please read the policy below and sign.
This office reserves the right to verify the credit status of potential patients and/or responsible parties prior to extending credit for treatment fees, and may, at the discretion of this office, use the services of one or more credit reporting services.

I acknowledge that I shall be responsible for collection fees and attorney fees or any unpaid balance on my account. My signature below is my agreement to be the financially responsible party for the account(s).

I also agree that, in the event that any unpaid balance, including principal, interest and late fees, is placed with or referred to a collection agency, attorney or other third-party collection service for collection, a fee of 35% of the unpaid balance shall be added to the unpaid balance due from me (an “authorized percentage collection fee”).

In addition to the unpaid balance due and the authorized percentage collection fee, I agree to pay all other costs incident to collection incurred directly or indirectly by Longos Middleton Neely Orthodontics or by the collection agency, attorney, or third-party collection service, to the total amount due from me or by having the opportunity to discuss it with Longos Middleton Neely Orthodontics staff, and that I agree of my own accord to the above provision.
Responsible Party:

First NameLast Name
Signature

Dental Insurance Information

Section 5
Policy Holder:

First NameLast Name
Date of Birth:
Social Security #:
Dental Insurance Carrier:
Member ID#:
Group#:
Patient relationship to Insured:
Employer:
Do you have dual coverage?
Policy Holder:

First NameLast Name
Date of Birth:
Social Security #:
Dental Insurance Carrier:
Member ID#:
Group#:
Patient relationship to Insured:
Employer:

Insurance Disclaimer

Please read the following disclaimer. The responsible party, not the insurance holder, must sign below.
Our goal is to help you maximize your dental insurance benefits. As a courtesy, we will bill your dental plan for services rendered. When we contact your insurance and verify benefits, it is not guarantee of payment by the insurance company, and benefits may vary from the verification according to your individual plan when the actual claim is submitted.

Any treatment plan that our office proposes to you is an estimate of what your insurance coverage will be; it is not a guarantee. If you need exact payment of benefits, then a pre-authorization is required. If you would like this to be done, you must notify our office staff before any work is initiated. This could take approximately 6-8 weeks.

In the event insurance pays less than the estimated amount, the balance will automatically roll over to the account of the responsible party. If an insurance overpayment is made, the account will be credited accordingly. Also, it must be noted that orthodontic insurance payments are made on a monthly, quarterly or yearly basis, depending on the insurance policy. In addition, if insurance has terminated and/or the orthodontic/dental maximum has been met, the remaining balance will be rolled to the patient/responsible party, and a statement will be mailed.

I understand Longos Middleton Neely Orthodontics cannot guarantee my insurance company will cover all services rendered and can only provide an estimate of benefits. I also understand that if my insurance company does not make payments, I will become the responsible party for that balance.
Responsible Party:

First NameLast Name
Signature

Required Consents and Policies

Please read the following statements and sign to indicate agreement.
DENTAL RECORDS CONSENT
Over the course of treatment, I agree to allow (or allow my child to have) photographs, X-rays or scans taken as necessary in order to complete treatment.
I further understand that there is not always a direct fee associated with these records and that costs will always be made clear prior to records being taken.
I also authorize and consent to allow Drs. Thomas J. Longos, Bethany R. Middleton & Alison F. Neely to release any necessary images and dental records to my dental care provider, oral surgeon, periodontist or any other needed dental-related specialist for the patient’s care and to my insurance company for the purposes of obtaining payment.

RESPECTFUL BEHAVIOR POLICY
At Longos Middleton Neely Orthodontics, we are committed to treating all individuals with dignity and respect, creating a welcoming environment for every patient. We ask that all patients and visitors maintain a positive and respectful attitude during their time with us. Aggressive, threatening, or disruptive behavior, whether verbal or physical, will not be tolerated. Should such behavior occur we reserve the right to discontinue care and ask the individual to leave the premises.
By signing below, I indicate I have read and understood this policy.

HIPAA CONSENT FORM FOR YOU OR YOUR CHILD
I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my/my minor child’s protection and health information. I understand that this information can and will be used to:

●Conduct, plan and direct my / my child’s treatment and follow-up among the multiple dental/ healthcare providers who may be involved in that treatment directly or indirectly. (Example - dentists or oral surgeons).

●Obtain payment from my insurance company

●Remind me of upcoming appointments, treatment options or alternatives.

My signature below indicates I have been given a copy or a chance to review an electronic version of the Notice of Privacy Practices for Longos Middleton Neely Orthodontics. This contains a more complete description of the uses and disclosures of my/my minor child’s health information to review prior to signing this consent.
I understand that Longos Middleton Neely Orthodontics has the right to change its Notice of Privacy Practices from time to time and that I may contact this office at any time to obtain a current copy.

A Notice of Privacy Practices form is available upon your request and also attached to the New Patient Form once submitted.

Understanding our Fee Policy:
We do our best to make treatment convenient and affordable. To keep appointments running smoothly for everyone, we ask that you review our fees related to payment timing, cancellations made with less than 24 hours’ notice, missed appointments and excessive broken brackets (more than two in one appointment / more than five during treatment).

We reserve the right to charge the following fees:
- $25 if an appointment is not kept and our office has not been notified at least 24 hours in advance.
- $25 for an insufficient funds charge or returned check.
- $20 for a late payment fee
- There is a lack of cooperation which results in longer treatment time. (fee varies)
- Bands, brackets, appliances or retainers are broken or lost through carelessness and need to be repaired or replaced. (fee varies; starts at $20 for excessive broken brackets)
- After two years of active retention, and at your request, additional checkups, adjustments, etc., will be performed and our usual charges will be rendered. (fee varies)
Signature
Authorization to Release Information: I authorize the following person(s) to have access to information covered under the Privacy Practice regarding myself or my child. This includes sharing Protected Health Information, including appointments or treatment information and decision-making about those. It is not mandatory to list anyone.

First NameLast Name
Relationship:
First NameLast Name
Relationship:
First NameLast Name
Relationship:
First NameLast Name
Relationship:
SOCIAL MEDIA CONSENT (OPTIONAL)
I consent to the use of patient's photographs to be published on the website, Facebook page, or any other public social media site held by the office of Drs. Longos, Middleton & Neely. These photographs may be used in promotional capacity within the office of Drs. Thomas J. Longos, Bethany R. Middleton & Alison F. Neely.
Signature
Type a question
Should be Empty:

New Patient Information Form

Patient Medical History

Patient Dental History

Responsible Party Information

Responsible Party Policy

Dental Insurance Information

Insurance Disclaimer

Required Consents and Policies