New Braunfels

Confidential Patient Information
Patient's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Home Phone
Birthdate

MonthDayYear
Date
Email Address
example@example.com
Social Security #
Gender

MaleFemale
If patient is a minor, give parent or guardian's name

First NameLast Name
Whom may we thank for referring you to our office?

First NameLast Name

Confidential Responsible Party Information
Name

First NameLast Name
Marital Status
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Home Phone
Socia Security #
Birthdate

MonthDayYear
Date
Relationship to Patient
Employer
Occupation
E-mail Address
Spouse's Name

First NameLast Name
Relationship to Patient
Social Security #
Birthdate

MonthDayYear
Date
Cell Phone

Insurance Information
Policy Holder's Name

First NameLast Name
Policy Holder's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate

MonthDayYear
Socia Security #
Employer
Insurance Company
ID #
Group #
Do you have dual coverage?

YesNo
If yes:
Please provide the name of your secondary dental insurance plan

Emergency Information
Name of nearest relative not living with you

First NameLast Name
Phone number
Relationship:
Signature(Parent's signature if minor)*

Clear

Orthodontic History

Please answer all questions for the patient if he/she is a minor and for yourself if you are the patient.
Describe in your own words what you understand the orthodontic problem to be:*
Whom may we thank for referring you to our office?
Has anyone in the family received orthodontic treatment by another orthodontist?
Names of any family members we have treated:
What is your attitude toward receiving orthodontic treatment?

PRIVACY CONSENT
This form is optional under the new patient privacy regulations recently issued by the United States Department of Health and Human Services. We have elected to use this form. Prior to commencing your orthodontic treatment, you should review, sign and date this form. 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 in connection with your treatment, payment of your account or health care operations (i.e., performance reviews, certification, accreditation and licensure.

You have the right to review our office’s privacy notice prior to signing this consent, a copy of which was given to you with this Consent.

You have the right to request restrictions on the use of your protected health information. However, we are not required to, and may not, honor your request. We may amend the attached privacy notice at any time. If we do, we will provide you with a copy of the changes, and the changes may not be implemented prior to the effective date of the revised notice.

You may revoke this consent at any time in writing. However, such revocation will not be effective to the extent that any action has been taken in reliance on this consent. Thank you for your cooperation. Please let us know if you have any questions.
Signature*

Clear
Date*

MonthDayYear
Date

PATIENT PHOTO RELEASE
Patient Name*

First NameLast Name
The above named patient (or parents/legal guardian) of New Braunfels Braces, consent to authorized the use and reproduction of photographs and audiovisual material whenever print or electronic format. I understand that these pictures, name, and only may appear in such publicity material for promotional and educational purposes only.*

I accept having my photo releasedI decline to have my photo released
Signature*

Clear
Should be Empty: