Adult Patient Form

Adult Patient Form
Patient Name (First & Last):*
I prefer to be called:
Email:*
example@example.com
Birthdate:*

MonthDayYear
Date
Age:
Gender:*

MaleFemaleNon-BinaryPrefer Not To Disclose
SS#:
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status:*

SingleDomestic PartnershipMarriedDivorcedWidowedSeparated
Cell Phone:*

Area CodePhone Number
Home Phone:

Area CodePhone Number
Work Phone:

Area CodePhone Number
Employer:*
Employer's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation:
Whom may we thank for referring you?*
Other family members seen by us:
General Dentist:*
Last Visit Date:
Spouse Information
Name:
Employer:
Work Phone:

Area CodePhone Number
Birthdate:

MonthDayYear
Date
Person Responsible for Account:*
Cell Phone:*

Area CodePhone Number
Work Phone:

Area CodePhone Number
Billing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relation:
Social Security Number:
Employer:
Primary Dental/Orthodontic Insurance
Do you have dental/orthodontic coverage?*

YesNo
Dental Insurance Co. Name:
Dental Insurance Co. Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental Insurance Co. Phone Number:

Area CodePhone Number
Group # (Plan, Local or Policy #):
Insured's Name:
Relation:
Insured's Birthdate:

MonthDayYear
Date
Insured's ID #:
Insured's Employer:
Secondary Dental/Orthodontic Insurance
Do you have dental/orthodontic coverage?

YesNo
Dental Insurance Co. Name:
Dental Insurance Co. Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental Insurance Co. Phone Number:

Area CodePhone Number
Group # (Plan, Local or Policy #):
Insured's Name:
Relation:
Insured's Birthdate:

MonthDayYear
Date
Insured's ID #:
Insured's Employer:
Emergency Contact

In the event of an emergency, is there someone who lives near you that we should contact?
His / Her Name:*
Cell Phone:*

Area CodePhone Number
Work Phone:*

Area CodePhone Number
Dental History
What are the main goals that you would like orthodontics to accomplish?
Have you ever had or been evaluated for orthodontic treatment?*

YesNo
Have you ever had a serious / difficult problem associated with any previous dental work?*

YesNo
Do you now or have you ever experienced pain / discomfort in your jaw (TMJ / TMD)?*

YesNo
Your current dental health is:*

GoodFairPoor
Do you like your smile?*

YesNo
Gums ever bleed?*

YesNo
Have you ever had an injury to your:*

MouthTeethChinNone
Do you have any speech problems? *
Do you generally breathe through your mouth while awake?*

YesNo
Do you generally breathe through your mouth while asleep?*

YesNo
Do you have any missing or extra permanent teeth?*

YesNo
Have you ever taken Fosamax, or any other bisphosphonate?*

YesNo
Have you ever taken Phen-Fen?*

YesNo
Do you smoke or use tobacco in any form?*

YesNo
Medical History
Do you have a personal physician?*

YesNo
Physician’s Name:
Phone Number:

Area CodePhone Number
Date of last visit:

MonthDayYear
Date
Your current physical health is:*

GoodFairPoor
Are you currently under the care of a physician? Please Explain.*
Are you taking any prescription / over-the-counter drugs? Please list each one.*
For Women: Are you using any prescribed method of birth control?

YesNo
For Women: Are you pregnant?

YesNo
For Women: Are you nursing?

YesNo
Have you ever had any of the following diseases or medical problems?*

Abnormal BleedingAnemiaArtificial Bones / Joints / ValvesAsthma / ArthritisBlood TransfusionCancer / ChemotherapyCongenital Heart DefectDiabetesDifficulty BreathingDrug / Alcohol AbuseEmphysemaEpilepsy / Seizures / FaintingFever Blisters / HerpesGlaucomaHeart Attack / StrokeHeart MurmurHeart Surgery / PacemakerHemophiliaHepatitisHigh / Low Blood PressureHIV / AIDSHospitalized for Any ReasonKidney ProblemsMitral Valve ProlapsePsychiatric ProblemsRadiation TreatmentRheumatic / Scarlet FeverSevere / Frequent HeadachesShinglesSickle Cell Disease / TraitsSinus ProblemsTuberculosis (TB)Ulcers / ColitisVenereal DiseaseNone
Please list any serious medical conditions that you have ever had:
Are you allergic to any of the following?*

AspirinAny Metals / PlasticsCodeineDental AnestheticsErythromycinLatexPenicillinTetracyclineFoods/Drugs/MaterialsOtherNone
Please list any other drugs/materials that you are allergic to:
Thank you for filling out this form completely.
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

This office reserves the right to verify the credit status of potential patients and / or parents of patients prior to extending credit for treatment fees and may, at the discretion of the office, use the services of one or more credit reporting services.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office.
Signature:*

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Date Submitted:*

MonthDayYear
Date
Privacy Notice
Patient Name*
Email Address
example@example.com
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your protected health information (i.e., individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:
- To other health care providers (i.e., your general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you (i.e., to determine the results of cleanings, surgery, etc.);
- To third-party payors or spouses (i.e., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e., to determine benefits, dates of payment, etc.);
- To certifying, licensing and accrediting bodies (i.e., the American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation;
- Internally, to all staff members who have any role in your treatment;
- To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling, etc.;
- To your family and close friends involved in your treatment; and/or
- We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke.

Under the new privacy rules, you have the right to:
- Request restrictions on the use and disclosure of your protected health information;
- Request confidential communication of your protected health information;
- Inspect and obtain copies of your protected health information through asking us;
- Amend or modify your protected health information in certain circumstances;
- Receive an accounting of certain disclosures made by us of your protected health information; and,
- You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our Privacy Contact Person at our office address) or the United States Secretary of Health and Human Services (which must be filed within 180 days of the violation).
We have the following duties under the privacy rules:
- By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information;
- To abide by the terms of our Privacy Notice that is currently in effect; and,
- To advise you of our right to change the terms of this Privacy Notice and to make the new notice provisions effective for all protected health information maintained by us, and that if we do so, we will provide you with a copy of the revised Privacy Notice.
Please note that we are not obligated to:
- Amend your protected health information if, for example, it is accurate and complete; or,
- Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.
This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Contact Person or direct your questions to this person at our office address. Thank you.

I hereby acknowledge that I have received and reviewed a copy of this Privacy Notice.
Signature*

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Date Submitted*

MonthDayYear
Date
Should be Empty:

Adult Patient Form

Spouse Information

Primary Dental/Orthodontic Insurance

Secondary Dental/Orthodontic Insurance

Emergency Contact

Dental History

Medical History

Thank you for filling out this form completely.

Privacy Notice