Confidential Patient Information
*First Name:
MI:
*Last Name:
Name preferred to be called:
*Birthdate:
*Gender:
Male
Female
*Address:
*City:
*State:
*Zip:
*Primary Phone:
Select Phone Type
Home Phone
Cell Phone
Secondary Phone:
Select Phone Type
Home Phone
Cell Phone
*Email:
Social Security #:
If patient is a minor, give parent's or guardian's name:
*Who does the patient live with?
Select
Self
Father
Mother
Parents
What school does the patient attend?
Is the patient adopted?
No
Yes
If yes, okay to discuss in front of patient?
No
Yes
Responsible/Custodial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
*First Name:
Middle Initial:
*Last Name:
*Marital Status:
Select
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
*Birthdate:
Address same as patient's
*Address:
*City:
*State:
*Zip:
*How long at this address?
Own
Rent
Previous Address (less than 3 years)
*Email:
*Primary Phone:
Select Phone Type
Home Phone
Cell Phone
Secondary Phone:
Select Phone Type
Home Phone
Cell Phone
Work Phone #:
Social Security #:
*Employer:
*Occupation:
*Length of Employment:
If applicable, complete for Spouse/Other parent
First Name:
Middle Initial:
Last Name:
Social Security #:
Birthdate:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Employer:
Occupation:
Length of Employment:
Work Phone #:
Dental Insurance Information
Policy Holder's Name:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Policy Holder's Address: (if different)
Insurance Company:
*Subscriber ID #:
Group No.:
*Policy Holder's Birthdate:
Insurance State:
Insurance Co. Phone No.:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Policy Holder's Address: (if different)
Insurance Company:
Subscriber ID #:
Group #:
Policy Holder's Birthdate:
Insurance State:
Insurance Co. Phone No.:
Emergency Information
Emergency Contact:
Phone:
Dental History
Dentist Name:
Last Dental Visit:
*Does the Patient need to premedicate for a medical condition prior to dental visit?
No
Yes
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?
No
Yes
Clench or Grind Teeth?
No
Yes
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
Injury to face, jaw, teeth or mouth?
No
Yes
Frequent headaches?
No
Yes
Jaw pain/tenderness?
No
Yes
Previous periodontal (gum) treatment?
No
Yes
Abnormal swallowing (tongue thrust)?
No
Yes
Mouth breathing?
No
Yes
Is there any dental work yet to be completed?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Has there been any change in the patient's general health within the last year?
No
Yes
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?
No
Yes
List any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Latex
No
Yes
Penicillin, Sulfa or other antibiotics
No
Yes
Metal Allergy
No
Yes
Aspirin, Ibuprofen, Tylenol, Codeine or other narcotics
No
Yes
Please give more detail to any "Yes" answered questions from above and list any other allergies:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Heart Condition: murmur, damage, valves, defects or disease
No
Yes
Rheumatic Fever
No
Yes
Liver Disease / Jaundice / Hepatitis
No
Yes
Kidney Disease
No
Yes
Heart Attack/Stroke
No
Yes
High or Low Blood Pressure
No
Yes
Blood disorder or bleeding disorders (hemophilia, anemia, prolonged bleeding)
No
Yes
HIV/AIDS
No
Yes
Tonsils/Adenoids Removed or Large Tonsils
No
Yes
Handicaps/Disabilities
No
Yes
Arthritis / Joint problems
No
Yes
Prosthetic joints
No
Yes
Bone Disorders/Bone Loss
No
Yes
Currently taking or have taken Bisphosphonates (Fosamax, Boniva)
No
Yes
Sinus trouble
No
Yes
Substance abuse problem (past or present)
No
Yes
Chronic fatigue
No
Yes
Diabetes
No
Yes
Cancer
No
Yes
Received Radiation Treatment
No
Yes
Arteriosclerosis
No
Yes
Thyroid / Endocrine / Growth Problems
No
Yes
Stomach ulcer or hyperacidity
No
Yes
Hormone Therapy
No
Yes
Nervous / Emotional Problems or Disorders
No
Yes
Seizures / Epilepsy / Neurological Disease
No
Yes
Asthma
No
Yes
Respiratory problems / Emphysema / Tuberculosis - Lung Disease
No
Yes
Persistent swollen neck glands
No
Yes
Sexually transmitted disease
No
Yes
Has patient begun puberty:
No
Yes
FEMALES: Are you pregnant
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
HIPAA POLICIES OF INDIGO ORTHODONTICS
NOTICE OF PRIVACY PRACTICES This notice describes how dental/medical information about you may be used and disclosed and how you can get access to this information. This notice describes the privacy policies of our office and does not govern the independent practices or operations of others. We do understand that dental and medical information about you and your health is personal. This notice applies to all of the records of your care generated by this office whether made by staff personnel or your personal doctor(s) and/or billing information. You will note no information will be released about you, your treatment, or payment history unless a signed release accompanies the request for information. There are some instances as directed by law that will require us to release information without your signed consent. They are listed as follows: We may use and disclose dental/medical information for treatment, payment, office operations or scheduling, appointment reminders, treatment alternatives, advising individuals involved in your care, as required or directed by law, military reasons, worker's compensation claims or illnesses, public health risks, Health oversight activities such as audits, investigations, inspections and licensure, lawsuits and disputes through court order, to coroners, to medical examiners, to funeral directors, to national security in accordance with intelligence activities, to protective services of the President and others as directed by authorized persons, to correctional institutions. YOUR RIGHTS REGARDING DENTAL/MEDICAL INFORMATION ABOUT YOU You have the right to inspect and request a copy in writing of your medical and dental health information and amend your records by submitting the amendment in writing stating reasons to support the amendment. Doctor's notes will not be amended but you may place in writing your opinions or notes to be recorded in your file. You have a right to notation of all disclosures, to restrict the information we disclose or limit the content to persons assisting with your care, to restrict or request a special or direct way of communication. We reserve the right to change this notice. You have the right to obtain an additional copy of this notice at any time. If you believe your rights have been violated at any time, you may contact or submit your complaint in writing to the Office Manager who in turn will notify the doctors. If we cannot resolve your concern(s), you also have the right to file a complaint with the Secretary of the Department of Health and Human Services. The quality of your care will not be jeopardized nor will you be penalized for filing a complaint. Other uses and disclosures of dental/medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose dental/medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back disclosures we have already made with your permission and that we are required to retain our records of the care that we provided you.
Yes
*I hereby acknowledge that I have read and received the HIPAA policies of Indigo Orthodontics.
Release of Information
I authorize the release of information, including the diagnosis, records, examination rendered to me, and claims information. This information may be released to:
Spouse
Child(ren)
Other
Information is not to be released to anyone.
THIS RELEASE OF INFORMATION WILL REMAIN IN EFFECT UNTIL TERMINATED BY ME IN WRITING
Messages
Please call:
my home
my work
my cell number:
If unable to reach me:
you may leave a detailed message
please leave a message asking me to return your call
other
The best time to reach me is (day)
between (time)
*I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.
*I understand that where appropriate, credit bureau reports may be obtained for financial arrangements.