New Patient Info/Health & Dental History

New Patient Information - Dental & Health History
What helped you decide to come to our practice? (select all that apply)

Other
Name of Friend(s)
Name of Family
Other (Write-in)
Office Location
The following information is for a(n):
Sex Assigned at Birth:
Gender Identity:
Gender Identity (Write-in)
Preferred Pronouns:

Other
Preferred Pronouns (Write-in)
Patient's Full Name:

First NameLast Name
Prefers to be addressed as:
Patient Birthdate

MonthDayYear
Best Phone Number to use for Communication:
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Alternate Email Address
example@example.com
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Home Address (if applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact in case of Emergency (Name):
Emergency Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Patient/Parent's Marital Status:
Person Responsible for Account:
Name of Person Responsible for Account (if different from patient)
Responsible Party Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you have children?
Child's Name (1)
Child's DOB

MonthDayYear
Date
Child's Name (2)
Child's DOB (2)

MonthDayYear
Date
Child's Name (3)
Child's DOB (3)

MonthDayYear
Date
Does the patient have siblings?
Sibling's Name
Sibling's DOB:

MonthDayYear
Date
Sibling's Name
Sibling's DOB:

MonthDayYear
Date
Additional Sibling Name(s) and DOB:
Name of School
Current grade
Release of Medical/Dental Information
I, the undersigned as the patient or their authorized representative (as decreed by law), do hereby authorize Lazin Orthodontics, to release to the noted insurance company(ies) or other appropriate agency(ies) that information which is necessary to valide an insurance eligibility and/or claim.

I hereby give permission to dislose (discuss and speak with) the personal medical/dental information about my or my child's treatment to the individuals listed below. Unless specifically listed below, Lazin Orthodontics may not speak to any individual concerning the medical or financial information for this patient - including appointments, test results, prescriptions, school or work excuses, etc. Please list all approved individuals including spouse, adult children, step-parents, grandparents, etc.) WE MUST HAVE THEM LISTED BY NAME AND SIGNATURE OF THE CUSTODIAL PARENT ON FILE. You may update this information at any time.
List the names and relationship of all authorized individuals:
e.g., John Smith (father) or Dr. Molar McFly (dentist)
HIPPA Consent

Click here to read the Notice of Privacy Practices
This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Consent officer or direct your questions to this person at our office address.
Authorization for Cell Phone and Email Use

I give my consent to receive regular unencrypted email or phone communications regarding treatment information, insurance, account, and billing information, and for regular unencrypted email correspondence with my dentist. I understand that I can withdraw my consent at any time.
Authorization for Cell Phone and Email Use
Preferred Contact Method
Certification
Certification:
My relationship to the patient is:
Patient Motivation

At Lazin Family Orthodontics, we are committed to providing the highest quality orthodontic care. We recognize that each patient and family has individual needs and expectations, and it is important to us to understand your priorities. Please help us understand what is important to YOU!
Briefly describe why you are seeking orthodontic treatment, what you are looking for in your orthodontic experience, and what we should know about you to best meet your needs.
Dental History
Do you have a Dentist?
Dentist's Name and/or Name of Dental Office
Date of Last Visit

MonthDayYear
Date
Is there anything about your dental history that Dr. Lazin should know?
Examples include previous orthodontic treatment, previous oral surgery, jaw problems, dental anxiety, or anything else you feel is important for us to know.
Has your dentist recommended any dental treatment that has not yet been completed?
Examples include fillings, crowns, extractions, implants, root canals, gum treatment, or other recommended dental procedures.
Have you had or do you presently have any of the following habits?
Have there been any injuries to the face, mouth or teeth?
Explain your injury
Are you aware of any missing or extra permanent teeth?
Please explain missing or extra permanent teeth
Are you aware of sores, lumps or irritated areas in the mouth?
Please explain sores, lumps, or irritated areas
Do you have bleeding gums?
Please explain bleeding gums
Has an orthodontist been consulted previously?
Orthodontist's Name:
Have you ever been treated for:
Do you have any speech problems?
Please explain speech problems
Reason for consultation (chief concern)
Please provide any additional dental history not listed above.
Has anyone in your family ever received orthodontic treatment (such as braces or Invisalign)?
If yes, please indicate their relationship to you (parent, sibling, etc.)
Were they satisfied with the results?
Dental Insurance
Do you have Dental Insurance?
Does your Plan have Orthodontic Coverage?
Name of Insurance Company
Insurance Company Phone:
Primary Member ID and/or SSN:
Many insurance companies (e.g., Delta Dental, MetLife, Guardian, HRI) use your social security number as the member ID. If no member ID is listed on your insurance card, the plan likely uses your SSN
Subscriber's Name:
Subscriber's Birthdate:

MonthDayYear
Date
Subscriber's Relationship to patient
Front of Insurance Card

Cancelof
Back of Insurance Card

Cancelof
Do you have Secondary Insurance?
Ortho Coverage?
Secondary Dental Insurance Company Name
Secondary Insurance Company Phone #
Member ID and/or SSN:
Subscriber's Name:
Subscriber's Birthdate:

MonthDayYear
Date
Relationship to Patient
Front of Secondary Insurance Card

Cancelof
Back of Secondary Insurance Card

Cancelof
Medical History
What is the name of your family physician?
Date of last physical

MonthDayYear
Date
Are you taking any medication?
Medication Names
Do you have any allergies? (Penicillin, Sulfa, Latex, etc.)
List allergies
Have you ever been advised by your physician to take an antibiotic prior to any dental treatments?
Antibiotic name and method
Pharmacy
DO YOU HAVE NOW, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? (Please select all that apply)
Other Medical Information Not Listed
I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION. I grant authority to the Doctor and Staff to perform all procedures and treatments in my best interest. I authorize the Orthodontist to share treatment information with collaborating dentists and surgeons when appropriate. I authorize the Orthodontist to submit treatment information pertinent to this patient to the Insurance Company for billing purposes only. Lazin Family Orthodontics may use your orthodontic records for educational and promotional purposes.
Printed Name
Patient/Parent's Signature
Should be Empty:

New Patient Information - Dental & Health History

Release of Medical/Dental Information

HIPPA Consent

Authorization for Cell Phone and Email Use

Certification

Patient Motivation

Dental History

Dental Insurance

Medical History