WebSite filled out New Patient Paperwork

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John C. Griffiths, D.D.S., M.D.S.

Douglas K. Simister, D.D.S., P.C.

Mark A. Whiting, D.M.D., M.S.

Today's Date *

Date

Preferred Email *

example@example.com

Patient Information

Is this form for yourself or a dependent? *

Myself Dependent

Patient's Full Name *

First Last

Preferred Name/ Nickname?

Patient's Gender? *

Female Male Do Not Wish To Answer

Patient's Date of Birth *

Date

Preferred Phone *

Area Code Phone Number

Type:

Please list cell phone provider so we may text you appointment reminders. *

(example Verizon, T-mobile, Sprint, etc)

Patient's Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

How long at this address? *

Does Patient Have Any Friends or Family Currently In Treatment at Our Office? (write N/A for not applicable) *

Whom may we thank for referring you to our office? (write N/A for not applicable) *

Reason for Consultation *

Employer (write N/A for not applicable) *

Occupation

# Years Employed

Work Phone

Area Code Phone Number

If Patient is under 18 years of age please list First Parent/ Guardian's Information

(type SELF in required fields if you are over 18 years old)

Parent / Guardian's Name *

First Name Last Name

Relationship to Patient *

Marital Status *

Address (if different from Patient's)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number *

Area Code Phone Number

Date of Birth *

Date

Social Security #

Financially Responsible? *

Yes No

Second Parent/ Guardian's Confidential Information

Parent / Guardian's Name

First Name Last Name

Relationship to Patient

Address (if different from Patient's)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number

Area Code Phone Number

Date of Birth

Date

Social Security #

Financially Responsible?

Yes No

Insurance Information

(If you do not have insurance type None in required fields)

Does Patient Have Insurance? *

Yes No

Primary Policy Holder's Name *

First Name Last Name

Relationship to Patient *

Policy Holder's Date of Birth *

Date

Please provide us with a copy of your current insurance card (Front & Back)

Front of Insurance Card

Back of Insurance Card

Social Security # *

Insurance Company *

Member ID # (if different from Social Security #)

Group #

Union Local # (If Applicable)

Insurance Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Insurance Company Phone

Area Code Phone Number

Policy Holder's Employer *

Do you have dual coverage?

If Yes, Secondary Policy Holder's Name

First Name Last Name

Relationship to Patient

Policy Holder's Date of Birth

Date

Please provide us with a copy of your current insurance card (Front & Back)

Front of Insurance Card

Back of Insurance Card

Policy Holder's Social Security #

Insurance Company

Member ID # (if different from Social Security #)

Group #

Union Local # (If Applicable)

Insurance Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Insurance Company Phone

Area Code Phone Number

Policy Holder's Employer

Emergency Information

Name of nearest relative not living with you *

First Name Last Name

Relationship to Patient *

Phone Number *

Area Code Phone Number

Medical History

Is Patient in Good Health? *

Does Patient have any History of Major Illness *

Please List (check any of the following for which patient has been treated)

Does Patient have tendency to colds? *

Sore Throats? *

Ear Infections? *

Have Tonsils and Adenoids been removed? *

What Age?

List any drugs or medications now being taken. Give reasons. (write N/A for not applicable) *

List Any Allergies or Drug Sensitivity: (write N/A for not applicable) *

Has the patient reached puberty? *

Girls- Has she started menstruation?

Boys- Has his voice changed?

Height

Weight

DENTAL HISTORY

General Dentist *

Last Cleaning

Date

Has there been any injuries to the face, mouth or teeth? *

Has the patient ever sucked a thumb or fingers? *

Until what age?

Does the patient have any speech problems? *

Is the patient a mouth breather? *

While awake?

While asleep?

Have you been informed of any missing or extra permanent teeth? *

Has an orthodontist been consulted previously? *

Has either parent had orthodontic treatment? *

Do you play any musical instruments? *

If yes which one(s).

Acknowledgment of Receipt of Statement of Privacy Practices

I acknowledge that I have recieved a copy of the Statement of Privacy Practices for the offices of Griffiths and Simister Orthodontics. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment or services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

Griffiths and Simister Orthodontics reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

ADDITIONAL DISCLOSURE AUTHORIZATION

In addition to the allowable disclosures described in the Statemet of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified below. (I understand that the default answer is "NO". Without indicating "YES" in answer to the each individual question, personal protected (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.)

Please list below who you would like us to your treatment information, financial information and/or appointment information with. *

(example any of my immediate family, Step Dad, patient's boyfriend, etc)

Patient signature or Parent/Guardian if a minor *

Clear