Patient Biographical Information    
*First Name:  
Middle Initial:
*Last Name:  
Nickname:
*Birthdate:    
*Gender:  
*Address:  
*City:  
*State:  
*Zip:  
*Main Phone:  
2nd/Cell Phone:
Email:
Social Security #:
Please list the names of any family currently in the practice:
List any sports, hobbies, or musical instruments played:
  Financial Party Information    
 
*First Name:  
Middle Initial:
*Last Name:  
*Address:  
*City:  
*State:  
*Zip:  
*Main Phone:  
2nd/Cell Phone:
Email:
Relationship to Patient:
Do you have insurance that covers orthodontics?

If so, please name the Insurance Company below:
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone #:
If minor, Other Parent Name:
Work Phone #:
  Insurance Information    
Primary Insurance
Policy Holder's Full Name: Insurance Co. Phone Number:
Policy Holder's Birthdate:   Employer:
ID Number: Group Number:
Relationship to Patient If Other, who?
  Dental History     
Dentist Name:
Check-up Frequency:
Last Dental Visit:  
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
  Speech problems/therapy?
  Grinding or clenching of teeth?
  Oral habits (thumb/finger sucking, lip/nail biting)?
  Injury to face, jaw, teeth or mouth?
  Discomfort in teeth or gums?
  Pain, tenderness or noise in the jaws?
  Frequent headaches?
If any of the above dental questions were answered 'Yes', please explain if needed:
   Medical History     
Physician Name:
Address:
City:
State:
Zip:
Date of last Physical:  
Patient Health:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
  Rheumatic Fever
  Tuberculosis/Lung Disease
  Pneumonia
  Liver Disease
  Kidney Disease
  Heart Attack/Stroke
  Heart Disease
  Congenital Heart Defect
  Heart Murmur
  Any condition requiring premedication for dental work
  Hemophilia
  Hypertension/High Blood Pressure
  Prolonged Bleeding/Transfusion
  Anemia
  HIV/AIDS
  Hepatitis
  Tonsils/Adenoids Removed
  Cancer
  Tatoo
  Metal Allergy
  Family History of Cancer
  Received Radiation Treatment
  Growth Problems
  Endocrine Problems
  Hormone Therapy
  Latex Allergy
  Nervous Disorders
  Behavioral Disorders (A.D.H.D., O.C.D., etc)
  Bone Disorders/Bone Loss
  Diabetes
  Seizures/Epilepsy
  Handicaps/Disabilities
  Asthma
  Arthritis
  Treated for Emotional Problems
  Ever Been Hospitalized
  Body Piercing
If any of the above medical questions were answered 'Yes' , please explain if needed:
  Patients Under 18    
If patient is under the age of 18, please answer the following questions:
Please list the name and birthdate of any siblings:
Height:
Weight:
School:
Grade:
Father/Guardian 1 Name:
Phone Number:
Mother/Guardian 2 Name:
Phone Number
With whom does patient reside:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has the voice changed or facial hair started:
Has the patient grown in the past year or has their shoe size changed recently:
Brush teeth daily?
Floss teeth daily?
Fluoride treatments?
 

 

 

 

 

PERSONAL REPRESENTATIVE, FAMILY OR OTHER ENTITIES WHO ARE AUTHORIZED ACCESS TO PROTECTED INFORMATION TO BE USED AND/OR DISCLOSE (OPTIONAL)  

Name of person and/or entities you are authorizing to make use of and/or to disclose your protected health information regarding treatment, payment and other healthcare operations.

Authorized Person or Entity: Relationship: Phone #:
Authorized Person or Entity: Relationship: Phone #:

AUTHORIZATION FOR USE OF ANSWERING MACHINE AND/OR VOICE MAIL

Burk & Flinn Orthodontics, PA doctors and staff are sometimes unable to contact patients directly during normal business hours. On these occasions our offices leave messages on communication devices provided by our patients. Due to the new federally mandated HIPAA Privacy Rule we must obtain your authorization to continue this mode of communication. Protected Healthcare Information that we may possibly disclose on your home, work or cell phone would include but is not limited to: prescription/pharmacy information, appointment instructions for visits and procedure, and scheduling information.

(Initial) I agree to allow Burk & Flinn Orthodontics, PA doctors and staff to leave messages that include Protected Healthcare Information of the following: Please initial next to the applicable communication devices:
Home Number Work Number Cell Number
(Initial) No, I do not agree to allow Burk & Flinn Orthodontics, PA doctors and staff to leave messages that include Protected Healthcare Information on my home, work and cell phone.
Signature:  
Date  

 I authorize my insurance carrier to release information regarding my insurance coverage to Burk & Flinn Orthodontics, PA. I also authorize agents of any hospital, treatment facility or previous physicians and or dentists to furnish Burk & Flinn Orthodontics, PA copies of any and all records of my medical and/or dental history. I authorize the release of my medical and/or dental records to any federal, state or accreditation agency. I agree to a review of my records for purpose of internal audits, research and quality assurance reviews within the office.

My right to payment for all procedures, supplies and services including major medical benefits are hereby assigned to Burk & Flinn Orthodontics, PA. This assignment covers any and all benefits under Medicare, all government sponsored programs, private insurance companies and other health plans. I acknowledge this document as a legally binding assignment to collect my benefits as payment for service. In the event my insurance carrier does not accept assignment of benefits, or if payments are made directly to my representative, or me, I will endorse such payment to Burk & Flinn Orthodontics, PA.

I understand that when paying by check to Burk & Flinn Orthodontics, PA, I will be responsible for a $30.00 fee if a check is returned. This does not include any other fees applied by your bank.

DIVORCED PARENTS of PATIENTS: By signing below, the adult who signs a minor child into our practice on the day of service accepts responsibility for payment. This office does not promise to send bills or records to the other parent/guardian for issues of payment communication. We will communicate about treatment and payment with the parent who is listed on the contract as the responsible party. Parents are responsible between themselves to communicate with each other about treatment and payment issues.

 

I understand that missed appointments and appointments cancelled without 24 hours notice are subject to a $25 fee. 

Signature:  
Date