• ADULT NEW PATIENT PACKET

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  • ORTHODONTIC HEALTH HISTORY FORM

  • Adult New Patient Packet • Please complete all sections. You will sign once, on the final page.

  • PATIENT INFORMATION

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How did you hear about us?*

  • SPOUSE / PARTNER & EMERGENCY CONTACT

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • YOUR FAMILY'S SMILES

  • Have children at home? The American Association of Orthodontists (AAO) recommends that every child have an orthodontic check-up no later than age 7. By then, an orthodontist can spot developing problems with the bite, jaw growth, and incoming teeth, many of which are still hidden beneath the gums. Checking early lets us guide jaw growth, make room for permanent teeth, and recommend the right treatment at the right time. Often no treatment is needed yet, just periodic check-ins. No dentist referral is needed.
  • Would you like us to schedule an orthodontic check-up for any child listed above?

  • INSURANCE INFORMATION

  • Insurance Status*
  • Format: (000) 000-0000.
  • Policyholder DOB
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Policyholder DOB
     - -
    2 digit month, 2 digit day, 4 digit year
  • Please note: Zammitti & Gidaly Orthodontics files claims with your primary dental insurance only. We do not bill secondary insurance, but we are happy to provide the claim forms, treatment details, and any other documentation you need to submit to a secondary plan.
    We only need a Social Security Number if your plan does not issue a Member ID. If so, our team will ask for it privately.
  • Concord: 10040 Edison Sq. Dr. NW, Concord, NC 28027 • Davidson: 130 Harbour Place Dr., Ste. 100, Davidson, NC 28036 • Harrisburg: 4079 Harris Sq. Dr., Harrisburg, NC 28075
    Zammitti & Gidaly Orthodontics • 704-947-9991 • charlottebraces.com • Health History • Page 1 of 7

  • ADULT NEW PATIENT PACKET

  • By completing this section, I authorize Zammitti & Gidaly Orthodontics to file claims with my dental insurance, release the information needed to process them, and receive payment directly from my insurance company. I understand that insurance benefits are an estimate, not a guarantee of payment, and that I am responsible for any balance not paid by my insurance.

    If you are not the policyholder: By completing this section, I confirm that I have the policyholder's permission and the legal authority to use this insurance for my care. I agree to keep the practice informed of any changes to this coverage, and I understand that if the policyholder or the insurance company does not pay, I remain responsible for the balance.

  • RESPONSIBLE PARTY (BILLING)

  • Good to know: Before orthodontic treatment begins, we will review your treatment fee and payment options with you, and a separate Orthodontic Financial Agreement (contract) will be signed. The person who signs that agreement will be financially responsible for the treatment it covers.

    If treatment is not recommended at this time, or if any other services are recommended or provided without a signed financial agreement (for example, records, observation visits, emergency or repair visits, or limited treatment), the person completing this paperwork is the responsible billing party for those charges.
  • Person completing this paperwork*
  • Format: (000) 000-0000.

  • DENTAL HISTORY

  • Format: (000) 000-0000.
  • Date of Last Cleaning / Exam
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you had previous orthodontic treatment (braces, aligners, or retainers)?*
  • Have you had any teeth removed, or are any teeth missing?*
  • Do you have crowns, bridges, implants, or veneers?*
  • Have you had gum disease, bone loss, or periodontal (deep cleaning) treatment?*
  • Any extra or impacted teeth, or unusual dental history?*
  • Have any teeth ever been bumped, chipped, or injured?*
  • Do you have jaw pain, clicking, popping, or locking (TMJ)?*
  • Do you gag easily?*
  • Are you nervous or anxious about dental or orthodontic visits?*
  • Do you play contact sports or a wind / brass instrument?*
  • Current or past habits (check all that apply)*
  • Concord: 10040 Edison Sq. Dr. NW, Concord, NC 28027 • Davidson: 130 Harbour Place Dr., Ste. 100, Davidson, NC 28036 • Harrisburg: 4079 Harris Sq. Dr., Harrisburg, NC 28075
    Zammitti & Gidaly Orthodontics • 704-947-9991 • charlottebraces.com • Health History • Page 2 of 7

  • ADULT NEW PATIENT PACKET

  • What matters most to you about treatment?*

  • MEDICAL HISTORY

  • Format: (000) 000-0000.
  • Date of Last Physical
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you in good health at this time?*
  • Are you currently under a physician's care?*

  • MEDICATIONS & ALLERGIES

  • Has a physician advised you to take an antibiotic before dental procedures?*
  • Do you take any medications (prescription or OTC), vitamins, or supplements?*
  • Do you take, or have you ever taken, bone-density medications (e.g., Fosamax, Boniva, Prolia) or long-term steroids?*
  • Allergic to any of these medications? (check all that apply)*
  • Allergic to any of the following? (check all that apply)*
  • Any physical, sensory, or other needs we can help accommodate?*
  • Concord: 10040 Edison Sq. Dr. NW, Concord, NC 28027 • Davidson: 130 Harbour Place Dr., Ste. 100, Davidson, NC 28036 • Harrisburg: 4079 Harris Sq. Dr., Harrisburg, NC 28075
    Zammit & Gidaly Orthodontics • 704-947-9991 • charlottebraces.com • Health History • Page 3 of 7

  • ADULT NEW PATIENT PACKET

  • MEDICAL CONDITIONS

  • Have you ever had, or do you currently have, a condition in any of the categories below? Mark No or Yes for each. If Yes, please list the specific diagnosis or details.
  • Heart (Heart murmur or defect, artificial heart valve, pacemaker, rheumatic fever, high / low blood pressure)*
  • Breathing, Lungs & Sleep (Asthma, COPD, breathing problems, sleep apnea, snoring, frequent sinus infections)*
  • Mental & Emotional Health (Anxiety, depression, ADD / ADHD, other conditions we should know about for your comfort)*
  • Neurological (Seizures / epilepsy, stroke, fainting or dizziness, frequent headaches or migraines)*
  • Vision, Hearing & Speech (Impaired vision, hearing, or speech)*
  • Hormone & Endocrine (Diabetes, thyroid conditions, hormone therapy)*
  • Blood Disorders & Infectious Disease (Bleeding disorders, anemia, blood thinners, hepatitis, HIV / AIDS, tuberculosis)*
  • Stomach, Liver & Kidney (Acid reflux, stomach / intestinal problems, liver or kidney disease)*
  • Cancer & Transplant (Cancer, tumor, radiation or chemotherapy (especially head / neck), organ transplant)*
  • Bones, Joints & Jaw (Osteoporosis / osteopenia, arthritis, joint replacement, TMJ / jaw problems)*
  • Genetic & Birth Conditions (Genetic syndromes, cleft lip or palate)*
  • Surgeries, Hospitalizations & Injuries (Any surgery or hospital stay, jaw surgery, head / face / jaw injury)*
  • Pregnancy / Nursing (if applicable) (Are you currently pregnant, possibly pregnant, or nursing?)
  • Other Medical Conditions (Any condition or concern not listed above)*

  • CERTIFICATION

  • I, the undersigned, have completed this form and certify that the information on it is true and correct to the best of my knowledge. I will notify Zammitti & Gidaly Orthodontics of any changes to my health or medications. THIS PRACTICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION NOT DISCLOSED. I authorize Zammitti & Gidaly Orthodontics to perform the diagnostic procedures needed to evaluate me and to recommend treatment in my best interest.
  • Acknowledged and signed on the Acknowledgment & Signature page at the end of this packet.
  • Concord: 10040 Edison Sq. Dr. NW, Concord, NC 28027 • Davidson: 130 Harbour Place Dr., Ste. 100, Davidson, NC 28036 • Harrisburg: 4079 Harris Sq. Dr., Harrisburg, NC 28075
    Zammitti & Gidaly Orthodontics • 704-947-9991 • charlottebraces.com • Health History • Page 4 of 7
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  • PRIVACY, COMMUNICATION & RELEASE OF INFORMATION

  • Adult New Patient Packet • Please complete all sections. You will sign once, on the final page.

  • NOTICE OF PRIVACY PRACTICES

  • COMMUNICATION PREFERENCES

  • I authorize Zammitti & Gidaly Orthodontics to contact me about appointments, treatment, and my account using the method(s) checked below. Standard message and data rates may apply. I may opt out of text messages at any time by replying STOP. I understand that email and text messages may not be encrypted.
  • Preferred contact methods (check all that apply and fill in)
  • Preferred Contact Methods*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • May we leave a detailed voicemail or message?*

  • RELEASE OF INFORMATION TO OTHERS

  • I authorize Zammitti & Gidaly Orthodontics to discuss my care with the individuals below (for example, a spouse, partner, or family member), limited to the information I check for each person.
  • Format: (000) 000-0000.
  • May share
  • Format: (000) 000-0000.
  • May share
  • Format: (000) 000-0000.
  • May share
  • These authorizations remain in effect until I revoke them in writing (704-947-9991). Treatment does not depend on signing them. Information shared with others may be re-disclosed and may no longer be protected by federal privacy law.

  • PHOTO & VIDEO RELEASE

  • We love celebrating our patients' smiles! By selecting "I give permission," I allow Zammitti & Gidaly Orthodontics to use photos and videos of my smile and results on our website, social media, and marketing materials. My full name will never be shared without separate permission. This choice is optional and will not affect my care.
  • Photo & Video Release Choices*

  • Acknowledged and signed on the Acknowledgment & Signature page at the end of this packet.

  • ADULT NEW PATIENT PACKET

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  • ORTHODONTIC OFFICE POLICIES

  • Welcome to our practice! We value a healthy, transparent relationship with every patient, built on trust and communication.

    Please read each section and initial where indicated.

  • APPOINTMENTS & SCHEDULING

    • CONSISTENT VISITS KEEP TREATMENT ON TRACK
      – Orthodontic treatment depends on regular adjustment appointments. Please schedule your next visit before leaving the office.
    • ARRIVAL TIME
      – Please arrive on time. If you expect to be more than 10 minutes late, please call us; we will do our best to accommodate you, but your appointment may need to be rescheduled.
    • CANCELLATIONS & RESCHEDULING
      – Please give at least 24 hours' notice if you need to reschedule.
      – Missed or repeatedly rescheduled appointments can lengthen treatment time.
    • APPOINTMENT REMINDERS
      – We send reminders by call, text, and/or email as a courtesy. Reminders are not a guarantee; please keep track of your scheduled visits.

  • FINANCIAL EXPECTATIONS

    • RESPONSIBLE PARTY
      – The person who signs the Orthodontic Financial Agreement is responsible for the treatment it covers, regardless of insurance coverage.
      – The person completing this packet is responsible for any services provided without a signed financial agreement.
    • TREATMENT FEES & PAYMENT ARRANGEMENTS
      – Your treatment fee and payment plan are reviewed with you and documented in a separate financial agreement before treatment begins.
    • INSURANCE
      – As a courtesy, we will file claims with your primary dental insurance. Benefits quoted are estimates only.
      – We do not bill secondary insurance, but we will provide the documentation you need to submit those claims.
      – Many plans limit or exclude orthodontic coverage for adults. We will verify your benefits, but coverage is not guaranteed.
      – Please notify us right away of any change in your insurance coverage.

  • DIAGNOSTIC RECORDS & CARE

    • I consent to the diagnostic records needed to evaluate and treat me, including x-rays, photographs, and digital scans or impressions. These records are part of my confidential health record.
    • Good results depend on teamwork. Please follow home-care, appliance, aligner, and elastic instructions, and keep regular cleanings with your family dentist during treatment.
    • Adult teeth and gums need extra care during treatment. Any dental work (fillings, crowns, or gum treatment) recommended by your dentist should be completed so treatment can stay on track.

  • Acknowledged and signed on the Acknowledgment & Signature page at the end of this packet.

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  • ACKNOWLEDGMENT & SIGNATURE

  • One signature covers every section of this packet. Please check each box to confirm.By checking each box and signing below, I, the patient (or the patient's authorized representative), confirm the following:*

  • PATIENT SIGNATURE

  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: