Welcome to our Practice

Which Deerwood Orthodontics office will be your primary location:
Patient First Name:
Patient Last Name:
Patient Birthdate:
Patient Gender:
Whom may we thank for referring you to our practice?
If Doctor or Friend/Family Referral, please provide their name:

Responsible Party Information

(Individual responsible for payment)

Relationship to patient:
Responsible Party First Name:
Responsible Party Last Name:
Responsible Party Birthdate:
Responsible Party Email:
Responsible Party Phone:
Responsible Party Address:
Responsible Party Address 2:
Responsible Party City:
State:
Zip Code:

Insurance Information

Primary Dental Insurance If there’s no dental insurance, mark n/a in each required field:
Policy Holder First Name:
Policy Holder Last Name:
Policy Holder Birthdate:
Policy Holder's Employer Name:
Policy Holder's Relationship to Patient:
Insurance Company Name:
Insurance Company Phone #:
Insurance Effective Date:
Insurance ID #:
Insurance Group #:
Insurance Company Address:
Insurance Company Address 2:
Insurance Company City:
State:
Zip Code:

Secondary Dental Insurance:
Policy Holder First Name:
Policy Holder Last Name:
Policy Holder Birthdate:
Policy Holder's Employer Name:
Policy Holder's Relationship to Patient:
Insurance Company Name:
Insurance Company Phone #:
Insurance Effective Date:
Insurance ID #:
Insurance Group #:
Insurance Company Address:
Insurance Company Address 2:
Insurance Company City:
State:
Zip Code:

Dental History

Please mark any of the following conditions that apply to you (patient).
Periodontal (Gum) Health
Pain/Discomfort
Habits
Function
Appearance
Comfort with Dental Treatment
General & Dental Health
Have you had an injury to the jaw, head, neck, or chin?
If yes, please explain
Is there any outstanding dental work to be completed? (i.e. crowns, extractions, cavities, etc that require treatment as diagnosed by your general dentist)
Current/Former Tobacco Use:
If yes, please indicate frequency and duration
Where would you rate your smile on a scale of 1-10, with 10 being the highest rating?
What would you like to change about your smile? (select all that apply)
If there's not a current general dentist, mark n/a in each required field.
Current dentist or clinic name:
Current dentist/clinic address, city, state:
Current dentist/clinic phone number:
Approximate date of last dental cleaning:
Has the patient had an orthodontic consult or treatment?
If so, when?

Patient Medical History

Please mark all current or historical medical conditions that apply to you (patient).

Women:
Do you take an antibiotic premedication for you dental visits?
If yes, please explain:
Are you under the care of a physician?
If yes, please explain:
Physician name, address, and phone number:
Date of Last Physical:
Have you had a serious illness, operation, or hospitalization in the past 5 years?
If yes, please explain:
Are you taking any prescription or over the counter medications?
Please list any medications you are currently taking, one medication per line:
Please list any medications or substitutes you are allergic to:
Have you ever in the past, or are you currently taking any Bisphosphonates or any other medications for Osteopenia/Osteoporosis or Bone Disease?
If yes, please list the medications:
Have you ever had surgery?
If yes, what type?
Please list any other medical conditions not identified above (or enter "None"):
I authorize Doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient's dental needs. I also authorize Doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk. I have read, understand and agree to the above terms and conditions.

Patients Under 18

If patient is under the age of 18, please answer the following questions:
School:
Grade:
Height:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or do they have facial hair?
Has the patient grown in height or shoe size in the past year?
Has either biological parent ever had orthodontic treatment:

Financial Policy

Thank you for choosing our office as your dental healthcare provider. We are committed to providing you with the highest quality lifetime dental care, so that you may attain optimum oral health. The following is a statement of our financial policy, which we require that you read, agree to, and sign prior to any treatment. Payment is due at the time service is provided. Our office accepts cash, personal checks, credit cards and outside patient financing. Please let us know if you would like more information about financing options.
Our office sends statements electronically, please provide the responsible party email address.

If you would like to change your statement preference, please contact the office.

Please Note: Returned checks will be subject to additional fees. In the case it becomes necessary for our office to enlist a collection service and/or legal assistance; you will be responsible for any collection and/or legal charges up to 35%.

Do You Have Insurance?

  • We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and your insurance company.
  • As a courtesy to you we will help you process all your insurance claims. Please understand that we will provide an insurance estimate to you, however, it is not a guarantee that your insurance will pay exactly as estimated. Your insurance company and your plan benefits will determine the amount paid. We will, of course, do all we can to make sure your estimate is as accurate as possible. If your insurance company has not made payment within 60 days, we will ask that you contact your insurance company to make sure payment is expected. If payment is not received or your claim is denied, you will be responsible for paying the full amount at that time.
  • We ask that you sign this form and/or any other necessary documents that may be required by your insurance company. This form instructs your insurance company to make payment directly to our office.
  • We ask that you pay the deductible and co-payment, which is the estimated amount, not covered by your insurance company, by cash, check, credit card or Patient Financing at the time we provide the service to you.
  • We will cooperate fully with the regulations and requests of your insurance company that may assist in the claim being paid. Our office will not, however, enter into a dispute with your insurance company over any claim.

We thank you for the opportunity to serve your dental health care needs and welcome any questions you may have concerning your care or our financial policy.

Acknowledgement of Receipt of Notice of Privacy Practices

Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgement.

**You may refuse to sign this acknowledgement**

I understand that I may inspect or copy the protected health information described by this authorization.

I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form.

I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality.

Authorization to Release Information

This form is used to obtain authorization to release information regarding yourself under the Privacy Act to people other than yourself. You may list multiple people or no one, if you wish.
Please type the name and relationship of the person(s) you authorize our practice to release information regarding yourself to.

HIPAA Authorization to Use and Disclose PHI for Marketing Purposes

PLEASE READ THIS AUTHORIZATION CAREFULLY. IF YOU CLICK “YES”, YOU AGREE TO BE BOUND BY THE TERMS FO THIS AUTHORIZATION. IF YOU DO NOT AGREE, CLICK “NO”. CLICKING EITHER BUTTON BELOW CONSTITUTES YOUR ELECTRONIC SIGNATURE.

  1. I authorize this dental office and it's Business Associates and Subcontractor Business Associates (collectively, “We” or “Us”) to use and disclose my health information (“Health Information”) for the purpose of delivering marketing messages to me and requesting feedback about my patient experiences, and suggestions as to how We can improve e-mail0 and/or text message offerings, to the e-mail address and/or mobile telephone number previously provided to Us (the “Authorized Purposes”). I understand that the frequency of these messages may vary.

  2. I understand that my Health Information may also include information provided by me or my health plan, or other health care providers, and also other publicly available information. I understand that my Health Information may be considered “Protected Health Information” (“PHI”) as defined under the Health Insurance Portability and Accountability Act of 1996, and it's implementing regulations (collectively, “HIPAA”).

  3. I authorized the use and disclosure of any Health Information or PHI by Us for this purpose.

  4. I understand that communications transmitted via unencrypted email, text message or over an open network may be inherently insecure, and there is no assurance of confidentiality for information communicated in this manner. I also understand that emails and text messages have inherent privacy risks, especially when access to my computer or mobile device is not password protected.

  5. I acknowledge that my signing of this Authorization is voluntary. I understand that I am not required to sign this Authorization, and my decision to sign or not sign will have no effect on my treatment, enrollment or eligibility or payment for benefits.

  6. I understand that, once Health Information or PHI has been disclosed pursuant to this Authorization, federal and state privacy laws may no longer protect the information from further disclosure. However, we agree to protect your Health Information and PHI by using and disclosing it only for the Authorized Purposes or as required by law or regulation.

  7. I understand that the Authorized Purposes described above may also involve direct or indirect financial remuneration from a third party in connection with the use or disclosure of my Health Information.

  8. I understand that I may revoke this Authorization at any time by notifying this dental office at the e-mail address listed at the top of this form; for text messages, by replying “STOP”; or for e-mail messages, by following the instructions in the e-mail to unsubscribe. Standard message and data rates may apply. I also understand that the revocation will not be effective until this dental office receives it but will not affect any actions taken by Heartland Dental in reliance on this Authorization prior to receiving electronic notice via e-mail of the revocation.

  9. I understand that I have the right to receive a copy of this Authorization for my records.

  10. This Authorization is valid from the date indicated below until the sooner of the date that this dental office or Heartland Dental on behalf of this dental office receives revocation, as described in paragraph 8, above, one year after the below date or as otherwise limited by applicable law.
Date:
Name of Individual Completing this Form:
Relationship to Patient:
Date:
Digital Signature