SMB Orthodontics Health History Form

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:

*How did you hear about our office?

*Who referred you to our office?

Financial Party Information

Check if the patient is also the person who will be financially responsible for treatment.

*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? NoYes 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.

NoYes	Speech problems/therapy?
NoYes	Grinding or clenching of teeth?
NoYes	Oral habits (thumb/finger sucking, lip/nail biting)?
NoYes	Injury to face, jaw, teeth or mouth?
NoYes	Discomfort in teeth or gums?
NoYes	Pain, tenderness or noise in the jaws?
NoYes	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.

NoYes	Rheumatic Fever
NoYes	Tuberculosis/Lung Disease
NoYes	Pneumonia
NoYes	Liver Disease
NoYes	Kidney Disease
NoYes	Heart Attack/Stroke
NoYes	Heart Disease
NoYes	Congenital Heart Defect
NoYes	Heart Murmur
NoYes	Any condition requiring premedication for dental work
NoYes	Hemophilia
NoYes	Hypertension/High Blood Pressure
NoYes	Prolonged Bleeding/Transfusion
NoYes	Anemia
NoYes	HIV/AIDS
NoYes	Hepatitis
NoYes	Tonsils/Adenoids Removed
NoYes	Cancer
NoYes	Tattoo

NoYes	Metal Allergy
NoYes	Family History of Cancer
NoYes	Received Radiation Treatment
NoYes	Growth Problems
NoYes	Endocrine Problems
NoYes	Hormone Therapy
NoYes	Latex Allergy
NoYes	Nervous Disorders
NoYes	Behavioral Disorders (A.D.H.D., O.C.D., etc)
NoYes	Bone Disorders/Bone Loss
NoYes	Diabetes
NoYes	Seizures/Epilepsy
NoYes	Handicaps/Disabilities
NoYes	Asthma
NoYes	Arthritis
NoYes	Treated for Emotional Problems
NoYes	Ever Been Hospitalized
NoYes	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:

NoYes

If patient is a girl, has menstruation begun:

NoYes

If patient is a boy, has the voice changed or facial hair started:

NoYes

Has the patient grown in the past year or has their shoe size changed recently:

NoYes

Brush teeth daily?

NoYes

Floss teeth daily?

NoYes

Fluoride treatments?

NoYes

Accept - I acknowledge that I have been informed of Privacy Practices required by HIPAA and can request a copy of the information.

Accept - No-interest payment plans are offered. If you would like to arrange payment by this means, a credit check will be necessary. The practice does not combine fee reductions. Only one reduction per patient when applicable.

Accept - If orthodontic records are taken and no treatment is started, I understand that I will be financially responsible for the records.

Accept - In the event insurance does not pay for treatment I am responsible for the balance based on my plan.

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

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

SMB 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 SMB 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 SMB 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 SMB Orthodontics, PA. I also authorize agents of any hospital, treatment facility or previous physicians and or dentists to furnish SMB 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 SMB 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 SMB Orthodontics, PA. I understand that when paying by check to SMB 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