Confidential Patient Information

* First Name:

Middle Initial:

* Last Name:

Nickname:

* Birthdate:

* Gender:

* Address:

* City:

* State:

* Zip:

* Main Phone:

2nd/Cell Phone:

Email:

Social Security #:

Please list the names of any friends or family currently in the practice:

List any sports, hobbies, or musical instruments played:

Whom may we thank for referring you to our practice?

Financial Party Information

Check if the patient is also the person who will be financially responsible for treatment.

* First Name:

Middle Initial:

* Last Name:

* Birthdate:

Relationship to Patient:

Email:

* Address:

* City:

* State:

* Zip:

* Main Phone:

2nd/Cell Phone:

* Social Security #:

Do you have insurance that covers orthodontics? NoYes

If so, please name the Insurance Company:

Member ID:

Group Number:

Subscriber's Name:

Subscriber's Birthday:

Dental History

Dentist Name:

Check-up Frequency:

Last Dental Visit:

Has the patient had an orthodontic consult or treatment?

NoYes If so, when?

What is the patients main orthodontic concern?

Please select YES or No for the Following Questions - Do Not Leave Blank

If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:

Date of last Physical:

Patient Health:

Address:

City:

State:

Zip:

List any medications currently being taken by the patient:

List any drug allergies or sensitivities that the patient may have:

Please select YES or No for the Following Questions - Do Not Leave Blank

If any of the above medical questions were answered 'Yes' , please explain:

Patients Under 18

If patient is under the age of 18, please answer the following questions:

Please list the name and birthdate of any siblings:

Height:

Weight:

School:

Grade:

Father/Guardian 1 Name:

Mother/Guardian 2 Name:

Has patient begun puberty: NoYes

If patient is a girl, has menstruation begun: NoYes

If patient is a boy, has their voice changed or have facial hair: NoYes

Has the patient grown in the past year or has their shoe size changed recently: NoYes

Patient's interest in treatment:

Has either biological parent ever had orthodontic treatment:

Cancelation Policy

When our office books your appointment, we are setting aside a dedicated chair and time slot just for you. We ask that if you must reschedule your appointment, you please provide us with at least 24 hours' notice. This courtesy makes it possible to give your reserved time slot to another patient who would be more than happy to accept.

There is a charge of $75 for canceling or not showing up for a scheduled treatment appointment with the general dentist, and $125 for missed appointments with any specialist.

Repeat cancellations or missed appointments will result in loss of future appointment privileges. This also includes late arrival times for appointments. 15 minutes or more into the scheduled appointment time will be considered a no show, and fee is applied.

Every patient in our practice receives this unique reservation. When your appointment is made, a time is reserved, your materials are ordered, and we make special arrangements to be ready for your visit. Except for emergency treatment for another patient, you can expect us to be prompt. We, of course, would appreciate the same courtesy from you

If you have any questions about this policy, one of our front desk team members or the Practice Manager would be happy to assist you.

HIPPA NOTICE OF PRIVACY PRACTICES

Federal protection for the privacy of health information and personal information is in effect. The HIPAA Notice of Privacy Practices for this dental office is available at the front desk when requested. Your signature below indicates that you are acknowledging notification of the privacy practices of this office.

ARBITRATION AGREEMENT

This dental practice agrees to provide to the undersigned patient dental health care services in consideration for the payment received. By signing this arbitration clause, you are agreeing to have any issue of dental malpractice decided by neutral arbitration and you are giving up your right to a jury or court trial. Your signature below indicates that you are acknowledging notification of the arbitration agreement of this office. Click here to view the Arbitration Agreement.

SOCIAL MEDIA AUTHORIZATION

At Fusion, we strive to create a family environment for our patients. We regularly interact with our patients and community through social media. We need your written consent if you would like us to include your smile in our online platforms.

You may use my first name & photo on your Web site gallery and social media pages. This may include Facebook, Google+, Twitter, Instagram, and Pinterest.

You may use my photo as referenced above, but no name.

I would prefer that my smile is not featured online.

FINANCIAL AGREEMENT

In an effort to maintain treatment fees at a minimum while maintaining a high level of professional care, we have established the following financial policy for our office. Please feel free to discuss our fees with us at any time. Before any dental treatment is begun, the patient and/or responsible party will receive a consultation regarding treatment plan and cost.

We require payment in full for the portion, not covered by dental insurance, of dental services to be rendered. For procedures that take multiple appointments to complete, payment may be split up over the number of appointments required. Any other financial arrangements shall be made only at the finance manager and/or doctor’s discretion. We accept cash, checks, Amex Visa, MasterCard, Discover, and upon request, we can also provide information regarding financial companies to help assist with the cost of your dental procedures such as Care Credit, and Citi Health. Credit applications for such financing options are available upon request.

As a courtesy to our patients with insurance, we will file your insurance claim, allowing you to pay only your deductible and/or estimated co-payment as services are rendered. Please remember that the contract is between you and your insurance company and your total balance in our office is always your responsibility. Please note that we allow 60 days for dental claim to be paid. We make every effort to give you an accurate estimate of what your portion of our fees will be, based on the information provided to us. However, we have no way to guarantee the actual terms of your policy. If for any reason there is a balance remaining after your insurance company’s payment, you will be sent statement. Any dispute regarding reimbursement or the amount of reimbursement is between you and your insurance carrier. By agreeing to this policy you agree to all such conditions.

We schedule our appointments to provide each patient with our undivided attention. In order to accomplish this, please be advised that you will be charged for cancellations with less than 24 hours notice at the rate of $50.00 for examination/hygiene appointments and $75.00 for dental procedures appointments. Also note that any type of deposits and/or payments towards the cosmetic cases will not be refunded. Should the patient change their mind for whatever reason during treatment, patient will be responsible for all costs incurred including lab fees and related costs.

An account with an unpaid balance past 60 days will be sent to a collection agency. At that time, you will be responsible for any and all costs incurred in the collection of your debt from the last date of service, such as attorney fees, court fees and any other fees associated with the collection of your debt.

Original records including radiographs are the property of this office. If you desire, we will provide you with a copy of your record or radiographs for a nominal duplication fee of $25.

We appreciate your confidence in choosing our practice. Please do not hesitate to inquire with a staff member should you have any questions regarding this policy.

I have read, understood, and agree to the Office Financial Policy stated above.