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 friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
  Financial Party Information    
 
*First Name:
Middle Initial:
*Last Name:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Carrier:
*Email:
Would you like email reminders?
Relationship to Patient:
Do you have insurance that covers orthodontics?
If so, please name the Insurance Company below:
ID #:
D.O.B.:  
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Would you like to view account online?
  Dental History     
*Dentist Name:
Check-up Frequency:
Last Dental Visit:  
Has the patient had an orthodontic consult or treatment?
If so, whom/when & were they happy?
What is the patient's main orthodontic concern?
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?
Grind or clench teeth?
Oral habits (thumb/finger sucking, lip/nail biting)?
Injury to face, jaw, teeth or mouth?
Discomfort from teeth or gums?
Pain, tenderness or noise in either jaw?
Frequent headaches?
Neck/shoulder pain?
Mouth breathing?
Medical condition that requires premedication?
Apprehensive about dental care?
Frequently Chew Gum?
Aware that some appts. will be during school/work?
Object to wearing appliances?
If any of the above dental questions were answered 'Yes', please explain:
   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 Problems
Heart Attack/Stroke
Heart Disease
Congenital Heart Defect
Heart Murmur
Hemophilia
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia
HIV/AIDS
Hepatitis
Tonsils/Adenoids Removed
Cancer
Family History of Cancer
Received Radiation Treatment
Growth Problems
Endocrine Problems
Hormone Therapy
Latex/Metal Allergy
Nervous Disorders
Bone Disorders/Bone Loss
Diabetes
Seizures/Epilepsy
Handicaps/Disabilities
Asthma
Arthritis
Treated for Emotional Problems
Ever Been Hospitalized
If any of the above medical questions were answered 'Yes' , please explain:
  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:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment:
  Assignment of Benefits  
Financial Responsibility
I understand that insurance billing is a service provided as a courtesy and that I am at all times financially responsible to Smile Straight Orthodontics and/or its affiliated entities for any charges not covered by dental benefits. It is my responsibility to notify Smile Straight Orthodontics of any changes in my dental coverage. In some cases exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill as determined by Smile Straight Orthodontics and/or my dental insurer if the submitted claims or any part of them are denied for payment. I understand that by signing this form, that I am accepting financial responsibility as explained above for all payment for dental services and/or supplies received.    
Initial:   
Assignment of Benefits
I authorize direct remittance of payment of all insurance benefits, including Medicare, if I am a Medicare beneficiary, to Smile Straight Orthodontics for all covered dental services and supplies provided to me during all courses of treatment and care provided by Smile Straight Orthodontics and/or its affiliated entities or otherwise at is direction. I understand and agree this Assignment of Benefits will have continuing effects for so long as I am being treated or cared for by Smile Straight Orthodontics, and will constitute a continuing authorization, maintained on file with Smile Straight Orthodontics, which will authorize and allow for direct payment to Smile Straight Orthodontics of all applicable and eligible insurance benefits for all subsequent and continuing treatment, services, supplies, and/or care provided by Smile Straight Orthodontics.     
Initial:   
Authorization to Release Information
I authorize the release of any medical or dental information to the Health Care Financing Administration, my insurance carrier(s), or other entity necessary to determine insurance benefits or the benefits payable for related dental services and/or supplies provided to me by Smile Straight Orthodontics. A copy of this authorization will be sent to the Health Care Financing Administration, my insurance carrier(s), or other dental entity, if requested. The original authorization will be kept by Smile Straight Orthodontics.     
Initial:   
Benefits of Orthodontics
I understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all of the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Smile Straight Orthodontics to perform a complete orthodontic evaluation.     
Initial:   
(H) Health (I) Insurance (P) Portability and (A) Accountability (A) Act
Our office has always emphasized the privacy of our patient’s personal information. As you may be aware, a governmental policy, HIPAA, regulates the use of patient’s personal information. As always, we will continue to use what personal information that is necessary to complete your treatment, insurance submittals, correspondence with your general dentist or oral surgeon, etc. Realize any further personal information is protected in our office. Please review the policy standards as they have been adopted in our office.
Initial: 
Signature:              Date: