Braces by Berry - Patient Information Form (Adult)

Emergency Contact Information
Emergency Contact

First NameLast Name
Relationship to Patient
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact Phone Type

HomeCellWork

Billing Information / Responsible Party
Is the patient the billing contact / responsible party?*

YesNo
Responsible Party*

First NameLast Name
Relationship to Patient*
Responsible Party Address*

Street Address

Apt / Suite

CityState

Zip Code
Responsible Party Driver's License Number*
Responsible Party's Driver's License State*
Responsible Party's Social Security Number*
Responsible Party's Spouse's Name (if applicable)
Responsible Party's Phone Number*
Please enter a valid phone number.
Responsible Party's Phone Type*

HomeWorkCell

Dental Insurance Information
Do you have dental insurance?*

YesNo
Is the patient the insured party?

YesNo
Do you have orthodontic coverage?*

YesNo
Member Name*

First NameLast Name
Relationship to Patient*
Member Date of Birth*

MonthDayYear
Date
Member Social Security Number*
Member Employer*
Insurance Company*
Insurance Company Phone*
Please enter a valid phone number.
Member ID*
Group Number*

Wrapping Up
How did you hear about Braces by Berry?*
Whom may we thank for the referral?*
Doctor / Family / Friend Name
Do you have additional family members seen by us?*

YesNo
Please list other family members and their relation.*
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 the 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.
Patient Signature*

Clear
Signature Date*

MonthDayYear
Date

Patient Consent to Use and Disclosure Information for Treatment, Payment, and Health Care Operations
Patient Name*

First NameLast Name
I, as the above stated patient understand that as part of my heath care, Dr. L. Ruth Berry, D.M.D., P.A. originates and maintains paper and/or electronic records describing my health history, symptoms, examinations, and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:
- A basis from planning my care and treatment.
- A means of communication among the dental professionals who contribute to my care, such as referrals.
- A source of information for applying my disagnoses and treatment information to my bill.
- A means which a third-party can verify that services billed were actually provided.
- A tool or routine operations, such as assessing quality reviewing the competence of staff.
I have been provided with a Notice of Patient Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:
- The right to view Notice prior to signing this consent
- The right to restrict or revoke the use or disclosure of my health information for other uses or purposes, and
- The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations, treatment, payment.
I wish to have the following restrictions to the use of disclosure of my health information.
Please tell us with whom we may discuss your treatment, payment or healthcare operations:
Example: relatives, friends, caregivers, and dentists.
I further understand that Dr. L. Ruth Berry, D.M.D., P.A. reserves the right to change her notice and practices per Section 164.520 of the Code of Federal Regulation. Should Dr. L. Ruth Berry, D.M.D., P.A., change her notice, I may request a copy of any revised notice in person (or by U.S. mail, to be sent to the address I have provided).
Appointment Reminders:
May we leave an appointment reminder message at your home using doctor's / practice name?*

YesNo
May we leave an appointment reminder message at your work using doctor's / practice name?*

YesNo
As part of treatment, payments, or healthcare operations, it may become necessary to disclose health information to another entity (i.e., referrals to other healthcare providers). I consent to such disclosure for these use as permitted by law.
I fully understand and accept or decline the terms of this consent.*

AcceptDecline
Patient Signature*

Clear
Signature Date*

MonthDayYear
Date

Photographic Waiver and Consent
So that we may provide you with the best possible state-of-the-art orthodontic services available, we feel it is necessary to take photographs. We would appreciate you taking the time to read and sign this consent form.

I hereby permit L. Ruth Berry, D.M.D., P.A., Dr. L. Ruth Berry, or any staff she may designate to take photographs for diagnostic purposes and enhance dental records. I agree that these photographs will remain the property of Dr. L. Ruth Berry.
Patient Name*

First NameLast Name
Patient Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Patient Information Form (Adult)

Emergency Contact Information

Billing Information / Responsible Party

Dental Insurance Information

Dental History

Medical History

Wrapping Up

Patient Consent to Use and Disclosure Information for Treatment, Payment, and Health Care Operations

Photographic Waiver and Consent