Patient Information & HIPAA Form

Patient Information & HIPAA Form
Patient Name *
Email *
example@example.com
DOB *

Month Day Year
Date
Sex *

Male Female
Identifies As
Cell Phone *

Area Code Phone Number
Alternative Phone

Area Code Phone Number
Social Security #
Have we treated any family members?
Who can we thank for referring you to our office?
I prefer to be seen in your:

Lawrence Office Topeka Office Baldwin Office
School
Hobbies
Who will be financially responsible for this account? *

Self Parent StepParent Grandparent
Name (If different from above)
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Social Security #
Driver's License #
Employer
Years Employed
Parent / Spouse 1
Name
Address (If different from above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
DOB

Month Day Year
Date
Social Security #
Phone Number

Area Code Phone Number
Email
example@example.com
Employer
Years Employed
Parent 2
Name
Address (If different from above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
DOB

Month Day Year
Date
Social Security #
Phone Number

Area Code Phone Number
Email
example@example.com
Employer
Years Employed
Insurance Information
Policy Holder
DOB

Month Day Year
Date
Policy Holder’s Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Member ID/ Social Security #
Name of Insurance Company
Employer
2nd Insurance Policy ( Even if there is no orthodontic benefit, please fill out)
Policy Holder
DOB

Month Day Year
Date
Policy Holder’s Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Member ID/ Social Security #
Name of Insurance Company
Employer
NOTICE: DO NOT SIGN THIS AGREEMENT BEFORE YOU READ AND AGREE TO THE CONDITIONS ABOVE. YOU ARE ENTITLED TO A COPY OF THIS AGREEMENT AT THE TIME YOU SIGN.
Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking, could have an important role with the dentistry you receive. Thank you for answering the following questions:
Dentist *
Date of Last Dental Cleaning *

Month Day Year
Date
Main Concern
Are you under a physician's care now? If yes, Name or Group Name?
Have you ever had a serious head or neck injury? If yes, please explain.
Are you taking any medications, pills, or drugs? If yes, please explain.
Have you ever taken Fosamax, Boniva, or Actonel? If yes, please explain.
Do you use controlled substances? If yes, please explain.
Do you use tobacco?

Yes No
Have you seen an orthodontist?

Yes No
Have you been treated by an orthodontist?

Yes No
Are you currently experiencing pain related to TMJ or other dental issues? If yes, please explain.
(Women) Are you pregnant/trying to get pregnant?

Yes No
Are you allergic to any of the following?

Aspirin Penicillin Metal/Nickel Latex Codeine Acrylic Sulfa Drugs Local Anesthetics
If yes, please explain.
Do you have, or have you had, any of the following?

AIDS/HPV Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Asthma Blood Disease Blood Transfusion Breathing Problems Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disease Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice
Have you ever had any serious illness not listed above? If so, please explain.
Comments
HIPAA RELEASE AND WAIVER

(Guide to Patient Privacy Rules Is in Waiting Room)
Signature For Health History

I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.
Patient/Responsible Party Signature *

Clear
Responsible Party Name *
Date *

Month Day Year
Date
Should be Empty:

Patient Information & HIPAA Form

Parent / Spouse 1

Parent 2

Insurance Information

Medical History

HIPAA RELEASE AND WAIVER

Signature For Health History