New Image Ortho English

Patient Name*

TitleFirst NameMiddle NameLast Name

Patient Gender*

Preferred Name

Patient Birth Date*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Responsible Party Name

Responsible Party Birth Date*

MonthDayYear

SSN*

### - ## - ####

Home Phone

Area CodePhone Number

Work Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

E-Mail*

Employer

Occupation

Are you a full-time student at a college?

YesNo

If yes, name of college

Marital Status:

How did you hear about our office?

Please check your preferred method of contact for appointment confirmation:

E-MAILCELL PHONEWORK PHONEHOME PHONE

Subscriber Name

Relationship to Patient

Subscriber DOB

Subscriber SSN/ID

Subscriber Employer

Insurance Company Name

Insurance Company Address

Insurance Company Phone

Area CodePhone Number

Group Number

Subscriber Name

Relationship to Patient

Subscriber DOB

Subscriber SSN/ID

Subscriber Employer

Insurance Company Name

Insurance Company Address

Insurance Company Phone

Area CodePhone Number

Group Number

Name

Relationship

Phone

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Name

Relationship

Phone

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Do you have a personal physician?

YesNo

Physician's Name

Physician's Phone

Area CodePhone Number

Date of Last Visit

Are you currently under the care of a physician?

YesNo

If yes, please explain

Do you use tobacco in any form?

YesNo

If yes, please list type and frequency of use

Do you have any artificial joints or implants?

YesNo

If yes, please list along with date of surgery

Are you taking any medication? If yes, please list each one

Have you ever had an allergic or unsual reaction to any of the following?

	Yes	No
Dental Materials?
Latex Materials?
Penicillin?
Erythromycin or Other Antibiotics?
Sulfa Drugs?
Any Other Medication or Drugs?

List all known allergies

Do you have any of these conditions?

	Yes	No
Abnormal Bleeding
Alcohol Abuse
Allergies
Anemia
Angina Pectoris
Arthritis
Artificial Heart Valve
Asthma
Bisphosphonates
Blood Transfusion
Cancer
Chemotherapy
Congenital Heart Defect
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy
Facial Surgery
Fainting Spells
Fever Blisters
Frequent Headaches
Glaucoma
HIV + AIDS
Heart Attack
Heart Murmur
Heart Surgery
Hemophilia
Hepatitis A
Hepatitis B
Hepatitis C
High Blood Pressure
Joint Replacement
Kidney Problems
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Pace Maker
Psychiatric Care
Radiation Therapy
Rheumatic Fever
Seizures
Sexually Transmitted Disease
Shingles
Sickle Cell Disease
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis
Ulcers

If Female, do you have any of these conditions?

	Yes	No
Are you taking birth control pills?
Are you nursing?
Are you pregnant?

If you are pregnant, how many weeks?

Dentist Name

Dentists Phone

Area CodePhone Number

How may we help you today?

Your current dental health is

GoodFairPoor

Do you know if you snore? Or "Has someone told you that you snore?"

YesNo

Please answer the following

	Yes	No
Do you require antibiotics before dental treatment?
Are you currently in pain?
Do you now or have you had any pain/discomfort in your jaw joint?
Are you aware of clenching or grinding your teeth?
Does it hurt when you chew or open wide to take a bite?
Do you have any jaw symptoms or headaches upon waking up in the morning?
Do you have pain in the face, cheeks, jaw, joints, throat or temples?
Do you like your smile?
Is there anything you would like to change about your smile?
Are you happy with the color of your teeth?
Have you ever had gum disease?
Do your gums bleed?
Have you ever had a deep cleaning or scaling and root planing?

How many times do you:

floss/week

brush/day

Please answer the following

	Yes	No
Are your teeth sensitive to heat, cold or anything else?
Do you take fluoride supplements?
Have you ever had a serious/difficult problem with any previous dental work?
Have you ever had any unfavorable dental experiences?
Are you apprehensive about dental treatment?
Do you gag easily?

When was your last dental cleaning?

When was you last dental visit?

How can we accommodate you better during your dental visit?

Is there any specific service and/or concern you would like to inquire about?

(Physical Signature Obtained at Dental Office.)

Print Name: ____________________________________________

Responsible Party Signature: ______________________________ Date:______________

( Physical Signature Obtained at Dental Office.)

Doctor Signature: _________________________ Date:_____________

I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to New Image Orthodontics, all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurances. I hereby authorize the New Image Orthodontics to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions. I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

Disclaimer:

All office personnel are New Image Orthodontics employees, except the Doctor. The Doctor is a licensed Orthodontist in the State of Arizona, but is an independent contractor. The Doctor and you, without input from anyone else, will determine the orthodontic services and treatment to be performed on you.

I understand that the Doctor is an independent contractor at New Image Orthodontics and not an employee.

Print Name: ____________________________________________

Responsible Party Signature: ___________________________________ Date:______________

( Physical Signature Obtained at Dental Office.)

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

· Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);

· Obtaining payment from third party payers (e.g. my insurance company) ;

· The day-to-day healthcare operations of your practice.

I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

Print Name: ____________________________________________

Responsible Party Signature: ___________________________________ Date:______________

( Physical Signature Obtained at Dental Office.)

Do you have any disease, condition or problem that you feel we should know about? If so, please describe

New Image Orthodontics Patient Information

Insurance - Primary

Insurance - Secondary

Nearest relatives not living with you:

Medical History

Dental History

Assignment and Release

Hipaa Consent