bailey-smiles.com - New Patient Registration Form

WELCOME TO BAILEY ORTHODONTICS

New Patient Registration
PATIENT INFORMATION
Today’s Date

MonthDayYear
Date
MaleFemale
Name:

First NameLast Name
Nickname:
DOB:

MonthDayYear
Date
School:
Grade:
College Student:

Full TimePart TimeN/A
Home Phone #:
Please enter a valid phone number.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient is:

ChildAdult
And resides with:

MotherFatherOther:
General Dentist:
Last Visit:
Frequency of dental visits:
Whom may we thank for referring you?
IF PATIENT IS A CHILD, PARENT/GUARDIAN INFORMATION
Marital Status:

SingleMarriedWidowedDivorcedSeparated
Mother’s Name:
DOB:

MonthDayYear
Date
SSN:
Employer:
Work #:
Please enter a valid phone number.
Cell #:
Please enter a valid phone number.
Home #, if different than child:
Please enter a valid phone number.
Email Address:
example@example.com
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Name:
DOB:

MonthDayYear
Date
SSN:
Employer:
Work #:
Please enter a valid phone number.
Cell #:
Please enter a valid phone number.
Home #, if different than child:
Please enter a valid phone number.
Email Address:
example@example.com
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PERSON RESPONSIBLE FOR ACCOUNT

IF OTHER THAN PARENT/GUARDIAN/SELF
Name:

First NameLast Name
Billing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home #:
Please enter a valid phone number.
Relation:
Employer:
Work #:
Please enter a valid phone number.
SSN :
Email:
example@example.com
PRIMARY DENTAL/ORTHODONTIC INSURANCE
Orthodontic Coverage?

YESNOUNSURE
Insurance Company Name:
Insurance Company Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone #:
Please enter a valid phone number.
Policy Holder:
Relationship to Patient:
Group #:
Policy #:
Policy Holder DOB:

MonthDayYear
Date
SSN:
Policy Holder’s Employer:
SECONDARY DENTAL/ORTHODONTIC INSURANCE
Orthodontic Coverage?

YESNOUNSURE
Insurance Company Name:
Insurance Company Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone #:
Please enter a valid phone number.
Policy Holder:
Relationship to Patient:
Group #:
Policy #:
Policy Holder DOB:

MonthDayYear
Date
SSN:
Policy Holder’s Employer:
PATIENT’S CURRENT HEALTH:
PHYSICAL:

ExcellentGoodFairPoor
EMOTIONAL:

ExcellentGoodFairPoor
KNOWN OR SUSPECTED ALLERGIES:
Antibiotics:
Other Medications:
Foods:
Environmental Allergies:
PlasticsLatexMetalsNoneOthers:
PLEASE INITIAL:*
CURRENT MEDICATIONS:

Heart MedicationsDiet aidsVitaminsInsulinBirth Control PillsMuscle RelaxantsAntiobiotics:Pain Medications:NONEOther:
Antiobiotics:
Pain Medications:
PLEASE INITIAL:*
If the patient is a child, has puberty begun?

YesNO
For girls, has menstruation begun?

YesNO
Patient’s Primary Care Physician:
Phone #:
Please enter a valid phone number.
Last Visit:
DOES/DID THE PATIENT HAVE ANY OF THE FOLLOWING HABITS?
Clenching/Grinding TeethNursing Bottle HabitsLip Sucking/BitingSpeech ProblemsMouth BreatherThumb/Finger SuckingNail BitingTongue ThrustRegularly snoresSleep disturbance:
PATIENT’S INTEREST IN ORTHODONTIC TREATMENT?
Desires treatmentOnly if necessaryUncooperativeUnwilling but will cooperate if treatment is indicated
ORTHODONTIC EXAM PROMPTED BY:
DentistDoctorParentSpouseSiblingFriendSelfOther:
HAS THE PATIENT EVER HAD ANY OF THE FOLLOWING MEDICAL PROBLEMS?
AIDS / HIV+AsthmaAutoimmune DisordersBlood disease/Abnormal BleedingBone DisordersHigh/Low Blood PressureDiabetesDizzinessEating DisordersEndocrine ProblemsHepatitisEmotional DisordersHeart DiseaseTuberculosisCongenital Heart DefectHeart MurmursHandicaps/DisabilitiesKidney DiseaseCancerRheumatic/Scarlet FeverConvulsions/EpilepsyRinging in the earsLiver ProblemsFrequent sore throat / tonsillitisMajor Surgeries:Hospital Admissions:
Major Surgeries:
Hospital Admissions:
Comments:
CHIEF ORTHODONTIC CONCERNS:
Please check all that apply:

CrowdingOverbite”Buck Teeth”Receded JawProminent JawGummy SmileNeck PainSpace between teethStuffy/Ringing EarsPain or Difficulty chewingHeadache/Face PainGum disease/recessionJaw dysfunctionJaw PainMouth too smallClicking Jaw JointIrregular TeethProtrusion of TeethIrregular Facial AppearanceOther:
FAMILY MEMBERS WITH SIMILAR CONDITIONS:

FatherMotherSiblingOther:
Has the patient ever been evaluated for or had orthodontic treatment before?

NoYes
Have there been injuries to the face, mouth, teeth, or chin?

NoYes
Any musical instruments played:
Adenoids/Tonsils removed?

YesNo
Any known missing or extra permanent teeth?

YesNo
Tenderness/Pain in jaw joint (TMJ / TMD)?

YesNo
Brush teeth daily?

YesNo
Floss Daily?

YesNo
MEDICAL, DENTAL, OR SURGICAL INFORMATION NOT COVERED ELSEWHERE ON THIS FORM?
PLEASE DESCRIBE:
PLEASE LIST A RELATIVE OR FRIEND NOT LIVING WITH YOU
Name:
Relation:
Phone Number:
Please enter a valid phone number.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in the patient’s medical status. I authorize the dental staff to perform any necessary dental services the patient may need.
Signature of patient or parent/guardian: *

Clear
Date:*

MonthDayYear
Date
I hereby authorize Bailey Orthodontics to release all necessary information to secure payment of benefits and I assign directly to the doctor all insurance benefits otherwise payable to me. I authorize use of this signature on all insurance submission. 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.
Signature of patient or parent/guardian:*

Clear
Date:*

MonthDayYear
Date
In order to provide the best possible orthodontic care, it may be necessary to communicate with other healthcare providers such as dentists, periodontists, oral surgeons, physical therapists, or other physicians regarding the patient’s treatment. Such permission to discuss issues pertaining to the patient’s orthodontic care shall be assumed and in effect unless and until revoked in writing by the patient or legal guardian. I acknowledge that I have received the NOTICE OF PRIVACY PRACTICES.
Signature of patient or parent/guardian:*

Clear
Date:*

MonthDayYear
Date
We follow state and federal regulations and recommended universal protection and disinfection protocols to limit transmission of all diseases in our office. Despite our careful attention to sterilization, disinfection, and use of personal barriers, due to the nature of the procedures we provide there is still a chance that you could be exposed to an illness in our office. Although exposure is unlikely, I accept the risk and consent to treatment.
Signature of patient or parent/guardian:*

Clear
Date:*

MonthDayYear
Date
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.
HIPAA PRIVACY AUTHORIZATION FORM
Patient Name:
**Authorization for Use or Disclosure of Protected Health Information
(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)**

**1. Authorization**
I authorize Bailey Orthodontics and Dr. John H. Bailey to use and disclose the protected health information described below to my general dentist and other healthcare providers as needed for orthodontic treatment.

**2. Effective Period**
This authorization for release of information covers:
Type a label   all past, present, & future periods
**OR**
Type a label   the period of healthcare from   Type a label   to   Type a label   .

**3. Extent of Authorization**
Type a label I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse).
**OR**
Type a label   I authorize the release of my complete health record with the exception of the following information:
Mental Health Records    Communicable Diseases (including HIV and AIDS)    Alcohol/Drug Abuse Treatment   Others (Please specify):   Type a label

4. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.

5. This authorization shall be in force and effect until   Type a label   (date or event), at which time this authorization expires.

6. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

7. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

8. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
Signature of patient or personal representative:

Clear
Printed name & relationship to patient:
Date:

MonthDayYear
Date
Should be Empty:

WELCOME TO BAILEY ORTHODONTICS

PATIENT INFORMATION

IF PATIENT IS A CHILD, PARENT/GUARDIAN INFORMATION

PERSON RESPONSIBLE FOR ACCOUNT

PRIMARY DENTAL/ORTHODONTIC INSURANCE

SECONDARY DENTAL/ORTHODONTIC INSURANCE

PATIENT’S CURRENT HEALTH:

DOES/DID THE PATIENT HAVE ANY OF THE FOLLOWING HABITS?

MEDICAL, DENTAL, OR SURGICAL INFORMATION NOT COVERED ELSEWHERE ON THIS FORM?

PLEASE LIST A RELATIVE OR FRIEND NOT LIVING WITH YOU

HIPAA PRIVACY AUTHORIZATION FORM