Health History Form, and HIPAA Privacy Practices Acknowledgement

Health History Form and Privacy Practices Acknowledgement - Adult
Thank you for scheduling an appointment at Montgomery Orthodontics. Prior to your first appointment, please complete Sections 1 - 9 of this form.

The information you provide will be sent to our office with secure encryption. Our office complies with HIPAA Privacy requirements (see Section 7 of this form). Completion of this form prior to your appointment will save you time during your visit to our office and will allow us to verify your insurance coverage.

You can expect that it will take approximately 10 minutes to complete this form. If you have any questions, please call our office at (609) 688-1611.

We look forward to seeing you.
Section 1: Patient Information
1. Patient Name*

First NameLast Name
2. Nickname (prefer to be called this name)
3. Current Age (years)*
4. Date of Birth*

MonthDayYear
Key in the date (no dashes) or use the date picker
5. Gender Identity*
6. Hobbies*
7. Whom may we thank for referring you to our office?
8. Other family members who are patients at our office

Section 3: Primary Orthodontic Insurance Information
1. Do you have primary orthodontic insurance coverage?*

YesNo
2. Subscriber's Name*

First NameLast Name
3. Subscriber's Date of Birth*

MonthDayYear
Key in the date (no dashes) or use the date picker
4. Dental Insurance Company*
Note, this is likely different than your Medical Insurance Company
5. Subscriber's Identification Number or Social Security Number*
6. Subscriber's Group Number*
7. Check any that apply:*

Dental benefits onlyDental and orthodontic benefits
8. Plan Type*

PPODMOOtherDon't know
9. Dental Insurance Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
10. Dental Insurance Company Phone Number*

Section 4: Secondary Orthodontic Insurance Information
1. Do you have secondary orthodontic insurance coverage?*

YesNo
2. Subscriber's Name*

First NameLast Name
3. Subscriber's Date of Birth*

MonthDayYear
Key in the date (no dashes) or use the date picker
4. Dental Insurance Company*
Note, this is likely different than your Medical Insurance Company
5. Subscriber's Identification Number or Social Security Number*
6. Subscriber's Group Number*
7. Check any that apply:*

Dental benefits onlyDental and orthodontic benefits
8. Plan Type*

PPODMOOtherDon't know
9. Dental Insurance Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
10. Dental Insurance Company Phone Number*

Health History Form and Privacy Practices Acknowledgement - Adult