Patient Information

Whom may we thank for referring you to our office?
Any family members/friends treated in our office? If yes, please list:
*Patient's Last Name:
*First Name:
M.I.:
*Date of Birth:
Age:
Height:
Weight:
*Social Security #:
Driver's License #:
*Address:
*City:
*State:
*Zip:
How long have you resided at this address?
*Main Phone:
2nd Phone:
Email:
Marital Status:
Sports/Hobbies:
What is your primary concern/what would you like the orthodontist to address or evaluate?
Have you been treated or evaluated by an orthodontist before?

Dental Insurance Information

Insurance Company Name:
Insurance Co. Phone Number:
Policy Holder:
Policy Holder D.O.B.:
I.D. #:
Social Security #:
Group #:
Employer:
Job Title:
How long with current employer?

General Dentist Information

Name of Dentist:
Phone Number:
Date of last visit:
Reason:

Physician Information

Name of Physician:
Phone Number:

Relative/Spouse Information

First Name:
Last Name:
*Address:
*City:
*State:
*Zip:
Home Phone:
Cell Phone:
Work Phone:

Medical History

Please check if the patient has any of the following conditions either now or in the past. The answers you provide are for office records only and will be considered confidential.
If applicable, list allergies/drug reactions:
Date of last physical:
Female Patients

Dental History

How often do you brush?
How often do you floss?
Realizing that successful treatment greatly depends upon the patient's complete cooperation in following instructions, keeping appointments, and maintaining oral hygiene; are there any restrictions, handicaps, or problems that might be encountered during treatment?
I understand the information I have given is true and correct to the best of my knowledge, it will be held at the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status.
I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in this form.
I understand Credit Bureau information may be obtained for office payment plans.
Patient Signature:

Agreement to Receive Electronic Communication

I agree that the dental practice may communicate with me electronically at the email address below.
I am aware that there is some level of risk that third parties might be able to read unencrypted emails.
I am responsible for providing the dental practice any updates to my email address.
I can withdraw my consent to electronic communications by calling: 954-452-9988 OR info@jacarandasmiles.com
Patient/Legal Guardian Signature:

Acknowledgement of Receipt of Notice of Privacy Practices

* You May Refuse To Sign This Acknowledgement *
I have received a copy of this office's Notice of Privacy Practices.
Name:
Signature:

About ICAT CBCT Cone Beam Scans

Jacaranda Orthodontics and Pediatric Dentistry now offers an exciting new technology for our patients and for patients of other doctors who might be referred here. This technology is called I-Cat Cone Beam Computer Assembled Tomography (CBCT) imaging, sometimes called 3-D radiographs or x-rays. Using CBCT means we now have the ability to take 3D images of the teeth, jaws, bones and facial structures at lower costs and with less energy than a typical CT scan used in hospitals. 3D imaging provides us the opportunity of improved diagnosis for our patients, especially in cases of impacted teeth, dental implants, surgical treatment, as well as more complex cases. Understandably you may have questions about exposure to these types of x-rays. Here are some facts you should know about 3-D imaging.
An ICAT CBCT exposure is:
  • About 1/2 as much as a full series of x-rays
  • About 1/5 as much as a full (28) mouth series of standard dental x-rays
  • About 1/70 as much as a typical medical CT scan
CBCT therefore offers our patients enhanced diagnostic value at a significantly reduced exposure. At the same time, CBCT scans can image the entire head and most of the neck. As dentists and orthodontists, we evaluate teeth, jaws and surrounding supporting bone, using CBCT’s for those limited purposes.
Our training and dental license does not provide for evaluating and diagnosing outside those areas. However since CBCT imaging can cover a broader area, we want to offer you the opportunity to have your CBCT scan read by an oral radiologist, trained and licensed to evaluate and diagnose a broader area. CBCT may show evidence of disease of the cervical spine, skull or arteries. We can refer you to a radiology group for this purpose. The average cost is about $ $195.00. If you are interested in taking advantage of this service please initial the application section and sign the acknowledgement below.
Signature of patient/responsible party: