LSO_New Patient Information (English)

PATIENT INFORMATION
Date:*

MonthDayYear
Date
Gender:*

MaleFemale
Birthdate:*

MonthDayYear
Date
Age:*
Patient's Name:*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Social Security #:*
School:
Grade:
If Patient is a minor, give parent’s or guardian’s name:
First and Last Name
List the names and ages of brothers and sisters or siblings:
(Ex: Brother - Age 7, Sister - Age 10)
How did you hear about our ofice or who reffered you?*
RESPONSIBLE PARTY INFORMATION
Name:
First and Last Name
Marital Status:
Mailing Address:
Street, City, State, and Zip
Email Address:
example@example.com
Cell Number:
Social Security#:
Birthdate:

MonthDayYear
Date
Relationship to patient:
Employer:
Occupation:
Work Number:
Spouse's Name:
First and Last Name
Relationship to patient:
Mailing Address:
Street, City, State, and Zip
SSN:
Birthdate:

MonthDayYear
Date
Work Phone
Please enter a valid phone number.
Cell Phone:
ORTHODONTIC INSURANCE INFORMATION
Primary Insured’s Name:
Social Security #:
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:

MonthDayYear
Date
Insurance Company:
Group No.:
Local No.:
Insurance Co. Address:
(123 Street Address, City, State and Zip)
Phone:
Insured’s Employer:
Address:
Street, City, State, and Zip
Do you have dual coverage?*

YesNo
If yes:
Secondary Insured's Name:
First and Last Name
Social Security #:
Mailing Address:
(123 Street Address, City, State and Zip)
Date of Birth:

MonthDayYear
Date
Insurance Company:
Group No.:
Local No.:
Insurance Co. Address:
Street, City, State, and Zip
Phone:
Insured’s Employer:
Address:
Street, City, State, and Zip
EMERGENCY INFORMATION
Name of nearest relative not living with you:*
First and Last Name
Relationship:*
Residence:*
(123 Street Address, City, State and Zip)
Phone:*
Signature (Parent's signature if minor)*

Clear

Please read the following:
LEGENDARY SMILES

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

**You May Refuse To Sign This Acknowledgment**
I,(Your Name) have received a copy of this office's Notice of Privacy Practices.
Please Print Name Below
Signature

Clear
Date

MonthDayYear
Date

Patient Communication Form
Your Name
Today's Date*

MonthDayYear
Date
Relationship to Patient(s):
Patient Name #1:
Patient Name #2:
Patient Name #3:
How would you like us to communicate with you?

Our orthodontic office sends appointment reminders, information about treatment, payment and insurance, and other communications including but not limited to newsletters, events, etc. Please tell us how you would like us to communicate with you.

Check or complete all that apply (please fill out completely):

	Select all that apply	Enter Mailing Address/Email Below:
Contact me by U.S. Mail at the following address:
Contact me by email at the following email address:

For Phone and Text Communications:

This form is optional. You are not required to sign this form, and you do not need to sign it to receive care in our orthodontic office.
Phone Number
Please enter a valid phone number.
By checking one of the boxes below, you are consenting to the following: The orthodontic practice may contact me to provide health care information such as appointment reminders and information about treatment, payment, my account or insurance, using artificial or prerecorded voice or telephone equipment that may be capable of automatic dialing. The orthodontic practice may:

Call meText meCall me and Text me
Signature

Clear
Date

MonthDayYear
Date
Thank you for taking the time to fill this out!
Should be Empty:

PATIENT INFORMATION

RESPONSIBLE PARTY INFORMATION

ORTHODONTIC INSURANCE INFORMATION

EMERGENCY INFORMATION

Legendary Smiles Confidential Patient Medical and Dental History

DENTAL AND ORTHODONTIC HISTORY

Patient Communication Form

Thank you for taking the time to fill this out!