New Patient Form-Orthodontic-Adult

Welcome to Southwest Pediatric Dentistry & Orthodontics!

Please take a few minutes to fill out this form as completely as you can. We look forward to being a part of your smile journey!
Patient Information

Adult Orthodontic Registration
Name*

First NameLast Name
Preferred Name
Gender*

MaleFemaleNon-binary
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Social Security #
Driver's License
Employer's name/occupation
Marital Status*

SingleMarriedSignificant OtherDivorcedWidowed
Spouse information
Emergency Contact Name & Relationship*
Emergency Contact Number*
Please enter a valid phone number.
Whom may we thank for referring you to our office?*
Insurance Information
Do you have dental/orthodontic insurance?*

YESNOUNSURE
Primary Insurance Company
Policy Holder Name

First NameLast Name
Relationship to Patient
Insured's Employer
Policy Holder DOB

MonthDayYear
Date
Policy Holder ID or SSN
Policy Group Number
Insurance Phone Number
Please enter a valid phone number.
Do you have Secondary dental insurance

YESNO
Secondary Insurance Company
Policy Holder Name

First NameLast Name
Relationship to Patient
Policy Holder DOB

MonthDayYear
Date
Policy Holder ID or SSN
Insured's Employer
Policy Group Number
Insurance Phone Number
Please enter a valid phone number.
Dental & Orthodontic History
What are the main concerns that you would like orthodontics to accomplish?*
Dentist or Practice Name*
Date of Most Recent Dental Exam*
Date Of Most Recent Dental X-Rays*
Do you currently have any dental work pending?*

YESNO
Please explain
I routinely see my dentist every*

3 Months6 Months12 MonthsNot Routinely
Your current dental health is*

GoodFairPoor
Do you like your smile?*

YESNO
Do your gums ever bleed?*

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

YESNO
If yes, please explain
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?*

YESNO
Have you ever had an injury to (select all that apply):

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

YESNO
Please Check All That Apply:*

Teeth GrindingSpeech problemsMouth breathing while awake and/or asleepHave been treated or diagnosed with periodontal problemsTonsils or Adenoids RemovedLip Sucking / BitingNail BitingDo you smoke or use tobacco in any form?NONE OF THE ABOVE
If yes to any of the above, please explain:
Have you had any previous orthodontic treatment or consultations?*

YESNO
If YES, what was completed, and by whom?
Has any other family member had orthodontics?*

YESNO
If YES, what was completed, and by whom?
Were the results acceptable?
Medical History
Are you allergic to any of the following?*

AmoxicillinAspirinAny Metals/PlasticsCodeine or other narcoticsDental Anesthetics (numbing meds)EggsErythromycinLatexPenicillinSodium pentothal/Valium/other tranquilizersSoySulfa drugsSulfitesTetracyclineOtherNONE OF THE ABOVE
Please list any other drug/materials that you are allergic to
Please check if you have a history of any of the following:*

Abnormal Bleeding/ bleeding tendencyAIDS/HIVArtificial Joints or ValvesAsthma or Hay FeverBlood Pressure ProblemsCancer, tumor, radiation treatment or chemotherapyCongenital Heart DefectConvulsions, Epilepsy or Fainting SpellsDiabetesDifficult BreathingDrug/Alcohol AbuseEmphysemaEndocrine, Thyroid or Growth ProblemsEpilepsy/Seizures/FaintingExcessive bleeding, anemia or bleeding disorderFever Blisters/HerpesHeart MurmurHeart Disease/SurgeryHeadaches, Severe/FrequentHeart Attack/StrokeHeart Surgery/PacemakerHemophiliaHepatitisImmunocompromisedInfections mononucleosisKidney/Liver DiseaseLow blood sugarMitral Valve ProlapseOsteoporosis/OsteopeniaMental Health Problems/anxiety/depressionPneumonia, bronchitis, chronic coughRheumatic/Scarlet FeverRheumatoid or Arthritic ConditionsShinglesSickle Cell Disease/TraitsSinus ProblemsSleep ApneaHistory of smoking/vapingThyroidTonsillitisTuberculosisUlcers/ColitisNONE OF THE ABOVE
If you answered yes to any of the above, please explain in more detail:
Is there any condition or problem not listed above that you think our office should know about?*

YESNO
Please explain
Is there any current medical treatment, impending surgery, or other treatment that may affect your dental treatment?*

YESNO
Please explain
Do you take antibiotic premedication for your dental visits?*

YESNO
Are you currently taking any prescription or over-the-counter medications?*

YESNO
Please list any medication you are currently taking:
Have you ever taken Fosamax or any other bisphosphonates?*

YESNO
Have you ever taken Phen-Fen?*

YESNO
Have you been hospitalized in the last 5 years (Illness or Injury)?

YESNO
Please explain*
Physician's Name, Speciality, Phone Number
For Females Only
Are you pregnant?

YESNO
Are you nursing?

YESNO
HIPAA ACKNOWLEDGMENT
ACKNOWLEDGMENT OF PRIVACY POLICY

As required by the HIPAA Privacy Regulations, all patients (or patient’s personal representative) who receive health care services on or after April 14, 2003 must:
- Receive and review the attached “Notice of Privacy Practices”, and
- Review and sign the “Acknowledgment Form” for our records.
I have been presented with a copy of this provider’s Notice of Privacy Policies below, detailing how my information may be used and disclosed as permitted under federal and state law.

Further, I permit a copy of this authorization to be used in place of the original. Please note that the attached Notice of Privacy Policies is not a consent form that must be read in full by the patient and signed before treatment can be provided; rather, the Notice provides each patient with a summary description of:
- How our office will use and disclose their medical information for legitimate business purposes,and
- How each patient can exercise their rights regarding this medical information. If you have any questions about this notice, please call our office at (303) 978-1104 and ask for our HIPAA compliance administrator.
I understand the contents of the Notice*

YESNO
I request the following restriction(s) concerning my personal medical information.
Please see the link below to obtain a copy of our Notice of Privacy Practices
CONSENT FOR DISCLOSURES TO FRIENDS AND /OR FAMILY MEMBER

I authorize Southwest Pediatric Dentistry & Orthodontics, PC to share my Protected Health Information to be disclosed for purposes of communicating results, findings, treatment decisions and financial issues to the family members and others listed below. This will serve as my electronic signature for the Consent for Disclosure Form (If a power of attorney, please provide a copy of the POA).
Full Name of Authorized Person/Relationship to Patient
FINANCIAL/INSURANCE AND OFFICE POLICIES
Payment Policy

Full payment is due at time of service. We accept cash, personal checks, Visa, MasterCard, American Express, Discover, and have payment plans available through CareCredit. If you have insurance, we will collect applicable copays/deductibles.

Returned Checks

Policy Returned checks are subject to a $35 return check fee.

Dental Benefits

You are responsible for understanding your dental benefits and have ultimate financial responsibility for your account, regardless of whether your dental insurance benefit covers part of your treatment. We are happy to provide you with an estimate of what we believe your dental benefits will cover based on information provided to us by your benefit provider. Dental services that require laboratory fabrication (e.g. athletic/night guards, pontics, retainers) require full payment at time of impression. Retail Products, Sonicare toothbrushes, Clinpro Toothpaste & whitening products are non-returnable and must be paid in full at time of purchase.

Past Due Accounts

Accounts more than 90 days past due may be transferred to a collection agency. Patients shall be responsible for all costs incurred for the collection of past due balances. This includes collection agency fees, attorney fees, and any other costs involved in litigation.
Financial policy agreement

I accept and understand the terms of the financial policy
INSURANCE ASSIGNMENT OF BENEFITS AUTHORIZATION

I authorize my insurance to pay my benefits directly to the dentist/office for all services rendered. I authorize the use of this electronic signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits. I acknowledge that I am financially responsible for all charges, whether or not paid by insurance. This will serve as my electronic signature for Assignment of Benefit.I do not authorize assignment of benefits and I will pay full fees at the time of service. I understand that the dentist office will print an insurance form for me to submit and my insurance will reimburse me directly.
Appointment policy

We realize that there are often circumstances in which you cannot control and we will try to work with you, so please let us know the reason for cancellation.
- 24-hour Cancellation/No Show policy – We request 24-hour cancellation notice in order to give other patients the opportunity to receive treatment. Please give us as much notice as possible when canceling an appointment.
- Late Arrival policy – In the event you arrive late for your appointment, your treatment will end at its scheduled time in order not to keep the next person waiting. Remaining services will be scheduled at another time.
Consent for electronic communication

To serve you better, Southwest Pediatric Dentistry and Orthodontics, PC (SWPDO) sends automated SMS Text Message and email appointment reminders. These reminders do not contain Protected Health Information (PHI). At your request, we can also communicate with you for scheduling appointments, providing PHI to you or an authorized recipient, or for other reasons that may contain your PHI. By selecting below, I authorize SWPDO to contact me by the means selected to the contact information.
- By authorizing, I acknowledge that I have read and understand the following: Message/data rates may apply to messages sent to my cell phone.
- I may opt-out of receiving these communications at any time by calling SWPDO at (303) 978-1104 or replying to the text or email as indicated in the message.
- As a general practice SWPDO does not send PHI by email, unless requested by the patient or authorized person to be sent by email. If I request anything containing my PHI to be sent electronically, I understand that PHI could possibly be read by unintended parties such as but not limited to the following: people that have access to my devices that receive my email, my email provider, my company (if using company email), stored on servers that are not HIPAA security compliant, etc.
Consent for SMS Text Messaging and Email

YESNO, I opt-out of electronic reminders and communication
I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge and will be held in the strictest of confidence. I understand that this information will be used by the treating provider to help determine appropriate and helpful dental or orthodontic treatment. I also understand that if there is any change to my, or the above-named patient's dental or medical status, it is my responsibility to inform the doctor. I authorize the dental staff to perform any necessary dental services that the patient may need during diagnosis and treatment with my informed consent. The parent and or guardian who accompanies the patient is responsible for payment at time of service unless prior arrangements have been provided. I understand that I am responsible for any amount not covered by insurance; including cost of collections, attorney, and court fees.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Welcome to Southwest Pediatric Dentistry & Orthodontics!

Patient Information

Insurance Information

Dental & Orthodontic History

Medical History

For Females Only

HIPAA ACKNOWLEDGMENT

FINANCIAL/INSURANCE AND OFFICE POLICIES