Patient Biographical Information    
*First Name:  
Middle Initial:
*Last Name:  
*Birthdate:    
Age:
*Gender:  
*Address:  
*City:  
*State:  
*Zip:  
*Main Phone:  
Email:
Parent Email:
2nd/Cell Phone:
Hobbies, Sports:
School:
Grade:
 Family members currently in orthodontic treatment?
Name of doctor:
  Family Information    
Family Member Name:
Birthdate:  
Gender:
Has had treatment:
Date of Treatment:
Family Member Name:
Birthdate:  
Gender:
Has had treatment:
Date of Treatment:
Family Member Name:
Birthdate:  
Gender:
Has had treatment:
Date of Treatment:
Family Member Name:
Birthdate:  
Gender:
Has had treatment:
Date of Treatment:
  Financial Party Information    
 
*First Name:  
Middle Initial:
*Last Name:  
Birthdate:  
Social Security #:
*Address:  
*City:  
*State:  
*Zip:  
*Residence Phone:  
Dental Ins. Co:
Group:
Employed by:
Work Phone #:
First Name:
Middle Initial:
Last Name:
Birthdate:  
Social Security #:
Address:
City:
State:
Zip:
Residence Phone:
Dental Ins. Co:
Group:
Employed by:
Work Phone #:
  Referral Information     
What is the patient's main orthodontic concern?
Whom may we thank for referring you?
Whom may we thank for referring you?
 
  Dental History     
Current Family Dentist:
Seen in last 6 months?
DO YOU HAVE OR HAVE YOU EVER HAD, ANY OF THE FOLLOWING
  Teeth sensitive to cold, heat, sweets?
  Bleeding gums?
  Swelling, lumps, or blisters in mouth/on lips?
  Complications from extractions?
  Periodontal treatment?
  Mouth breathing?
  Tonsils/Adenoids Removed?
  Thumb/finger sucking?
  Oral habits (finger, nail or cheek biting)?
  Clenching or grinding of teeth?
  Clicking, grating, pain in ear or jaw joint?
  Received a severe blow to head or chin?
  Frequent neck aches and/or headaches?
  Difficulty in opening mouth?
  TMJ or bite treatment?
  Pain in head or neck that interferes with work or activity?
  Do you feel you need treatment for any of these problems?
  Would you be willing to engage in invasive elective oral surgery to obtain "The ideal orthodontic result?"
   Medical History     
Physician Name:
Seen in last 12 months?
Medical Ins. Co.:
DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING
  Heart Murmur or Other Heart Ailments
  Rheumatic Fever
  Hypertension/High Blood Pressure
  Allergies to Drugs or Anesthetics
  Allergy to Latex or Metals
  Allergies or Asthma
  Malignancies
  Radiation Treatment
  Excessive Bleeding from Cut or Extraction
  Anemia, Blood Problems, or Blood Transfusions
   
   
  Pregnant
   
  DO YOU NEED TO BE PRE-MEDICATED FOR ANY HEART AILMENTS?
  Cancer
  Liver problems or Hepatitis
  Arthritis or Osteoporosis
  Kidney Problems
  Psychiatric care/emotional problems
  Neurological Problems
  Thyroid
  Tuberculosis
  Diabetes
  HIV or ARC
   
   
If yes, what month?
   
List any medications currently being taken by the patient:
Health Information: I      certify that this information is correct.
 
Insurance: To avoid misunderstanding regarding dental insurance, we wish the persons responsible to know that all professional services renderedare charged directly to them and that they are personally responsible for payment or fees. We will prepare necessary forms or reports to help the persons responsible to obtain benefits from insurance companies for receipt of full (or partial) payment of bill. We do not render our services on the basis that insurance companies will pay all our fees. Each fee is indvidual for the individual patient. All information contained on this form will remain confidential.
 
HIPAA: ACKNOWLEDGMENT OF PRIVACY POLICY
 
This form is optional under the new patient privacy regulations recently issued by the United States Department of Health and Human Services. We have elected to use this form. Prior to commencing your orthodontic treatment, you should review, sign and date this form.
Your protected health information (i.e., individually identifiable information such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used in connection with your treatment, payment of your account or health care operations (i.e., performance reviews, certification, accreditation and licensure).
You have the right to review our office's privacy notice prior to signing this Consent, a copy of which is available upon request.
You have the right to request restrictions on the use of your protected health information. However, we are not required to, and may not, honor your request.
We may amend the attached privacy notice at any time. If we do, we will provide you with a copy of the changes, and the changes may not be implemented prior to the effective date of the revised notice.
You may revoke this Consent at any time in writing. However, such revocation will not be effective to the extent that any action has been taken in reliance on this Consent.
Thank you for your cooperation. Please let us know if you have any questions.
 
Insurance Protocol
We are committed to providing you with the best possible care, and are pleased to discuss our professional fees with you at any time. Your clear understanding of our Insurance Protocol is important to our professional relationship.
We must emphasize that our relationship is with you, not your insurance company. It is your responsibility to provide us with any and all changes that may occur regarding your insurance information.
Your insurance is a contract between you, your employer, and the insurance company.
We will process your insurance claims as a courtesy to you with the information you provide us. This will serve as signature on file for the submission of all insurance claims and assignment of benefit to the above named office.
Many services that are delivered in our practice (i.e.; cosmetic appliances) are not necessarily included in your insurance benefits. Therefore any difference in fees will be your responsibility.
It is your responsibility to make sure payments are made in a timely manner.
Please make sure our office is aware of any changes in your insurance coverage or carrier.
If for any reason your insurance does not pay, it will be necessary for us to bill you
Any insurance account over 6 months past due will automatically be billed to you.
Thank you for understanding our Insurance Protocol. If you have any questions about the above information, please ask us. We are here to help you.
1. I have read the above information. I understand and agree that I am responsible for the payment of all professional services rendered.
2. I authorize any and all payment from my insurance company directly to Orthodontic Professionals, P.C.
3. I authorize the release of any medical information necessary to process your insurance claims.
Pateint/Parent or Guardian's Name: