Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Street Address:
City:
State:
ZIP Code:
If you don't have a social security number, please put all 0's.
Main Phone #:
2nd/Cell Phone #:
Email Address:
Social Security #:

If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?
Please list the names of any friends or family currently at Aligner Experts:
List any sports, hobbies, or musical instruments played:
How did you hear about Aligner Experts?

Financial Party Information

First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Birthdate:
Street Address:
City:
State:
ZIP Code:
Email Address:
Main Phone #:
2nd/Cell Phone #:
Work Phone #:
If you don't have a social security number, please put all 0's.
Social Security #:

Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
If you don't have a social security number, please put all 0's.
Relationship to Patient:
Social Security #:
Birthdate:

Dental Insurance Information

Do you have insurance?
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Do you have dual dental coverage?
(If yes, complete information below)

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:

Emergency Information

Name:
Primary Phone #:
2nd/Cell Phone #:
Relationship to Patient:

Dental History

Dentist Name:
Check-up Frequency:
Last Dental Visit:
Has the patient ever had an orthodontic consult or treatment? If so, when?
Does the patient need to premedicate prior to dental visit?
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.
Select here if all answers BELOW are NO
Speech Problems/Therapy?
Clench or Grind 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?
Chipped or Injured Permanent Teeth?
Previous Periodontal (Gum) Treatment?
Mouth Breathing?
Apprehensive about Dental Care?
Do you have any pending dental work?
If any of the above dental questions were answered 'Yes', please explain:
Do you have a history of jaw joint problems, clicking, popping, or difficulty opening your mouth?
Do you have any history or current symptoms of TMJ? If yes, please describe:

Medical History

Does the patient have any allergies or drug reactions to:
Select here if all answers BELOW are NO
Latex
Penicillin or Other Antibiotics
Sulfa Drugs
Aspirin, Ibuprofen, Tylenol
Local Anesthetics
Metal Allergy
Other:
List any drug allergies or sensitivities (not listed above) 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.
Select here if all answers BELOW are NO
Heart Murmur
Damaged or Artificial Heart Valves
Congenital Heart Defect
Heart Disease
Rheumatic Fever
Angina
Liver Disease/Jaundice/Hepatitis
Kidney Disease
Heart Attack/Stroke
Hemophilia
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia/Blood disorder
HIV/AIDS
Tonsils/Adenoids Removed
Handicaps/Disabilities
Arthritis/Joint problems
Large Tonsils
Sinus Trouble
Bed Wetting
Substance Abuse Problem (Past or Present)
Bone Fractures/Trauma to Face/Jaw
Prosthetic Joints
Chronic Fatigue
Diabetes
Growth Problems
Tuberculosis or Lung Disease
Pneumonia
Cancer
Family History of Cancer
Received Radiation Treatment
Arteriosclerosis
Thyroid/Endocrine Problems
Stomach Ulcer or Hyperacidity
Hormone Therapy
Nervous Disorders
Bone Disorders/Bone Loss
Seizures/Epilepsy/Neurological Disease
Treated for Emotional Problems
Asthma
Respiratory Problems/Emphysema
Persistent Swollen Neck Glands
Sexually Transmitted Disease
Low Blood Pressure
Persistent Cough
Heart Condition
Autoimmune Disorder
Are you pregnant?
Do You Take Bisphosphonates (Fosamax, Boniva)
Has there been any change in the patient's general health within the last year?
If any of the above medical questions were answered 'Yes' , please explain:

NOTICE OF PRIVACY PRACTICES (NPP) AND ACKNOWLEDGEMENT

TO THE PATIENT—PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.

NOTICE OF PRIVACY PRACTICES:

Click here for a copy or ask and a paper copy will be provided to you.

I acknowledge that I have received the Aligner Experts’ Notice of Privacy Practices.

If this Acknowledgement is signed by a personal representative on behalf of the patient, complete the following:
Personal Representative’s Name:
Relationship to Patient:
Patient or Responsible Party Signature:
Date:

CONSENT FOR PHI USE, DISCLOSURE, AND EMAILING OF X-RAYS

PURPOSE OF CONSENT:
By signing this form, you consent to Aligner Experts use and disclosure of your protected health information (PHI) to carry out treatment, payment, and healthcare operations.

REVOCATION:
You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to our Privacy Official listed in our NPP. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you, or to continue treating you.

I have had full opportunity to read and consider the contents of this Consent form and understand that, by signing I give my consent to your use and disclosure of my protected health information to carry out treatment, payment and healthcare operations.

EMAILING X-RAYS:
To provide the best treatment to our patients, it may be necessary for us to email x-rays to other specialists or dentists. This allows other offices to have better diagnostic tools available to them.

I understand that x-rays may need to be emailed to other specialists and dentists and give my permission to do so.
Patient or Responsible Party Signature:
Relationship to Patient:
Date:

CONSENT FOR RECORDS

Consent to Examinations
I authorize the performance of diagnostic record examinations including, but not limited to, the following: comprehensive photos, panoramic and cephalometric x-ray images, diagnostic intraoral scan, impressions, etc.

I consent to these records for myself/my child for which Aligner Experts requires to evaluate orthodontic needs and determine treatment recommendations.
Release of Liability During Pregnancy
This is to certify that, to the best of my knowledge, I am not pregnant or that I consent to the capture of records during pregnancy. I give permission to Aligner Experts to perform diagnostic record examinations on myself/my child. I have been advised that there is an inherent risk associated with certain x-ray examinations that can be potentially harmful to an unborn child.
Patient or Responsible Party Signature:
Relationship to Patient:
Date: