Health History Form

Health History Form
Submit Your New Patient Forms to Miller Orthodontics!!

Save time at the our office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form, click the "Submit Form" button at the bottom, and your information will be sent to our office with secure encryption. We will already have your information when you arrive for your first appointment.

Items marked with asterisk (*) must be completed.
First Name**
Last Name**
I prefer to be called (Nickname)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Email Address*
example@example.com
Birth date (MM DD YYYY)**

MonthDayYear
Date
Gender*

MaleFemaleNon Binary
Social Security Number (Adults only)
If patient is a minor, give parent's or guardian's name
Whom may we thank for referring you to our office?*
Other Family members seen at our office
School/Employer
Hobbies/interests
RESPONSIBLE BILLING PARTY #1
Full Name**
Relationship to Patient (put 'Self' if it is you)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address**
example@example.com
Cell Phone Number*

Area CodePhone Number
Work Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Social Security Number *
Birth date (MM DD YYYY)*

MonthDayYear
Date
Employer
Occupation*
Marital Status
RESPONSIBLE BILLING PARTY #2
Full Name
Relationship to Patient
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Social Security Number
Birth date (MM DD YYYY)

MonthDayYear
Date
Cell Phone Number

Area CodePhone Number
Work Phone

Area CodePhone Number
Employer
Dental Insurance Information
Primary Insured's Name (write "NONE" if there isn't any)*
Primary Insured's Birthdate (MM DD YYYY)

MonthDayYear
Date
Primary Insured's Social Security Number
Primary DENTAL Insurance Company (please write "NONE" if there isn't any)*
Primary Policy ID Number
Primary Group Number
Primary Insurance Co. Phone Number

Area CodePhone Number
Do you have dual coverage?

YesNo
Secondary Insured's Name
Secondary Insured Birthdate (MM DD YYYY)

MonthDayYear
Date
Secondary Insured's Social Security Number
Secondary DENTAL Insurance Company
Secondary Policy ID Number
Secondary Group Number
Secondary Insurance Co. Phone Number

Area CodePhone Number
Medical Health History
Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.
Primary Care Physician*
Date of Last Visit

MonthDayYear
Date
Primary Care Physician Phone Number

Area CodePhone Number
Please check any of the following which apply to you, and add any relevant comments.
Are you taking any medication?*

YesNo
If yes, list medications:
Are you allergic to any medication?*

YesNo
If yes, list medication allergies:
Are you allergic to latex?*

YesNo
Please list any other allergies:
Do you have a history of any major operations/illness?*

YesNo
If Yes, please list here:
Have you had any major accidents*

YesNo
Are there any medical conditions we have not discussed that you feel we should be aware of?*
Please check any of the following that you have had or currently have:*

Abnormal Bleeding/HemophiliaArthritisAnemiaAsthmaBone disordersCongenital Heart DefectCOVID-19 / CoronavirusCancer/TumorDiabetesEpilepsyDizzinessGI DisordersHerpesHeart ProblemsHepatitis/Live ProblemsHeart MurmurHigh Blood PressureKidney ProblemsNervous DisordersPneumoniaRheumatic FeverRadiation/ChemotherapyTuberculosisNone of the AboveOther
Dental History
General Dentist*
Date of Last Visit*

MonthDayYear
Date
What concerns you most about your teeth?*
Please check any of the following which apply to you, and add any relevant comments.
Are you presently in any dental pain?*

YesNo
Have you ever lost or chipped any teeth?*

YesNo
Have there been any injuries to face, mouth or teeth?*

YesNo
Do you have any type of tongue or thumb habit?*

YesNo
Are you aware of your jaws clicking or popping?*

YesNo
Are you aware of clenching or grinding your teeth during the day or night?*

YesNo
Do you have 'tension" headaches?*

YesNo
Have you ever seen an orthodontist?*

YesNo
If yes, please explain (orthodontic treatment or a consult only?)
Do you have Obstructive Sleep Apnea?*

YesNo
Please list any other sleep disturbances (eg snoring, insomnia, fatigue):
HIPAA Disclosure

HIPAA Privacy Notice
Miller Orthodontics is obligated under the HIPAA Act to protect the privacy of protected health information (PHI) and to provide you with a notice of ourprivacy practices. You may request a copy of our privacy practices at anytime. For more information about our privacy practices, or for additional copies, please contact us using the information available on this notice.I consent to have Miller Orthodontics use and disclose my PHI forpayment, treatment and healthcare operations purposes, and for suchother purposes that are permitted under HIPAA or other Federal or State law without my written authorization
By clicking yes, I certify that I fully understand the HIPAA policy for Miller Orthodontics and that I agree to the aforementioned terms and conditions regarding my PHI*

YesNo
Photo Disclosure

Privacy Notice
I hereby grant to Miller Orthodontics the irrevocable and unrestricted right to take, use, and publish photographs and/or digital images of me, or in which I may be included, for electronic reproductions (official website, Facebook, Twitter, or YouTube), educational materials, and/or promotional materials or any other purpose and in any other manner or medium. These materials might include printed or electronic publications. In addition, I grant my permission to alter the same without restriction; and to copyright the same. I further agree that my name and identity may be revealed in descriptive text or commentary in connection with the images. I authorize the use of these images without compensation to me. I hereby release the photographer and Miller Orthodontics from all claims and liability relating to said photographs. By clicking yes, I certify that I fully understand the Photo disclosure policy for Miller Orthodontics as stated and that I agree to the aforementioned terms completely.*

YesNo
Patient/Guardian Signature"*

Clear
By typing your name in this box, you are signing this document with a digital signature.

By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface. Submit
Should be Empty:

Health History Form

RESPONSIBLE BILLING PARTY #1

RESPONSIBLE BILLING PARTY #2

Dental Insurance Information

Medical Health History

Dental History

HIPAA Disclosure

Photo Disclosure