Child - New Patient Information Form

Child New Patient Information
PATIENT LEGAL NAME:*

First NameLast Name
PREFERRED NAME:
GENDER:*
DATE OF BIRTH:*

MonthDayYear
Date
CURRENT AGE:*
INTERESTS: (Sports/Activities/Things that make you smile)
SCHOOL:
GRADE:
REFERRED BY:
HAD ORTHODONTIC CONSULT BEFORE?

YESNO
PAST/PRESENT FAMILY IN TREATMENT AT OUR OFFICE?
PARENT 1 INFORMATION
NAME:*

First NameLast Name
DOB:*

MonthDayYear
Date
MARITAL STATUS/ SPOUSE'S NAME:*
EMAIL:*
example@example.com
PHONE:*
Please enter a valid phone number.
ADDRESS:*

Street Address

Street Address Line 2

CityState

Zip Code
EMPLOYER:*
OCCUPATION:*
PARENT 2 INFORMATION
NAME:

First NameLast Name
DOB:

MonthDayYear
Date
MARITAL STATUS/ SPOUSE'S NAME:
EMAIL:*
example@example.com
PHONE:
Please enter a valid phone number.
ADDRESS:

Street Address

Street Address Line 2

CityState

Zip Code
EMPLOYER:
OCCUPATION:
DENTAL INSURANCE INFORMATION
DO YOU HAVE DENTAL INSURANCE COVERAGE?*

YESNO
INSURANCE COMPANY:*
SUBSCRIBER NAME:*
DOB:*

MonthDayYear
Date
SUBSCRIBER SSN:
MEMBER ID:*
EMPLOYER:*
GROUP NUMBER:*
INSURANCE ADDRESS:

Street Address

Street Address Line 2

CityState

Zip Code
INSURANCE PHONE:*
Please enter a valid phone number.
DO YOU HAVE ADDITIONAL INSURANCE COVERAGE?*

YESNO
INSURANCE COMPANY:*
SUBSCRIBER NAME:*
DOB:*

MonthDayYear
Date
SUBSCRIBER SSN:
MEMBER ID:*
EMPLOYER:*
GROUP NUMBER:*
INSURANCE ADDRESS:

Street Address

Street Address Line 2

CityState

Zip Code
INSURANCE PHONE:*
Please enter a valid phone number.
MEDICAL INFORMATION/HISTORY
DENTIST:*
LAST CLEANING:*

MonthDayYear
Date
PHYSICIAN NAME:*
LAST EXAM:

MonthDayYear
Date
PLEASE CHECK ALL THAT APPLY:*

WATER IS FLUORINATEDFLOSSES DAILYTAKES FLUORIDE SUPPLEMENTBRUSHES AT LEAST TWICE DAILYGUMS BLEEDN/A
PLEASE INDICATE IF PATIENT HAS: (CHECK ALL THAT APPLY)*

BEEN EVALUATED FOR ORTHO TREATMENT BEFOREEVER RECEIVED AN INJURY TO THE FACE, MOUTH, TEETH OR CHINHAD ADENOIDS/TONSILS REMOVEDBEEN INFORMED ABOUT MISSING OR EXTRA PERMANENT TEETHBEEN TOLD TO TAKE ANTIBIOTICS PRIOR TO DENTAL VISITSHAD PROBLEMS WITH PREVIOUS DENTAL WORKN/A
CURRENTLY TAKING OR EVER TAKEN A BISPHOSPHONATE? INCLUDES ANY MEDICATION USED TO MAKE BONES STRONGER, SUCH AS:*

BONIVAACTONELFOSAMARN/AOther
PLEASE CHECK ANY HABITS PATIENT HAS:*

CLENCHING/GRINDING TEETHLIP SUCKING/BITINGEXCESSIVE SNORINGMOUTH BREATHINGNAIL BITINGNURSING/BOTTLE HABITSPEECH PROBLEM/SPEECH THERAPYTHUMB/FINGER SUCKINGTOBACCO USETONGUE THRUSTUSED PACIFIERN/A
LIST MEDICATIONS CURRENTLY TAKING AND REASON:*
ANY ALLERGIES OR REACTIONS TO ANY OF THE FOLLOWING:*

ASPIRIN, TYLENOL, IBUPROFENBARBITURATESCODEINE OR OTHER NARCOTICSLATEXLOCAL ANESTHETICSMETALSPENICILLIN OR OTHER ANTIBIOTICSPLASTIC OR VINYLSEDATIVESSLEEPING PILLSSULFA DRUGSN/AOther
PLEASE LIST ANY SERIOUS MEDICAL PROBLEMS THE PATIENT HAS EXPERIENCED:*
NOW OR IN THE PAST HAS THE PATIENT HAD:*

ABNORMAL BLEEDINGCHICKEN POXENDOCRINE/GROWTH DISORDERHEPATITISLIVER PROBLEMSHANDICAPS/DISABILITIESSKIN RASHTUBERCULOSISANEMIAEPILEPSYCANCERHIV/AIDSLUPUSHEMOPHILIA/BLOOD DISORDERARTIFICIAL BONES/JOINTSHEARING IMPAIRMENTHEART MURMURHIVESMEASLESDIABETESKIDNEY PROBLEMSASTHMACHRONIC SINUS PROBLEMSCONGENITAL HEART DEFECTHOSPITAL STAYSMITRAL VALVE PROLAPSEMONONUCLEOSISTROUBLE SLEEPING/SLEEP APNEANONE
EMERGENCY CONTACT:*
RELATIONSHIP:*
PHONE NUMBER:
Please enter a valid phone number.
PATIENT SURVEY
WHY ARE YOU SEEKING ORTHODONTIC TREATMENT?*
WHO WERE YOU REFERRED BY?*
HOW DID YOU LEARN ABOUT H & K ORTHODONTICS?

PLEASE TELL US HOW IMPORTANT THE FOLLOWING ARE TO YOU:*

	NOT	SOMEWHAT	IMPORTANT	VERY	EXTREMELY
LENGTH OF TREATMENT TIME
COMFORT OF TREATMENT
LATEST TECHNOLOGY
CLEAR/INVISIBLE
LOW DOWN PAYMENT
QUALITY OF TREATMENT
INTERESTED IN STARTING WITHIN THE MONTH

SIBLING INFORMATION (if applicable):
PLEASE LIST THE NAME, AND AGE OF ANY CHILDREN/FAMILY MEMBERS WHO MAY BE INTERESTED IN ORTHODONTIC TREATMENT IN OUR OFFICE IN THE FUTURE
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
SECTION A: PARENT/LEGAL GUARDIAN GIVING CONSENT
PARENT/LEGAL GUARDIAN NAME:
PATIENT LEGAL NAME:
SECTION B: TO THE PATIENT - PLEASE READ THESE STATEMENTS CAREFULLY

PURPOSE OF CONSENT: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations.

NOTICE OF PRIVACY PRACTICES: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activities and healthcare operations of the uses and disclosures we may make of your protected health information and of other important matters about your protected health information. A copy of our notice is available upon request with this consent. We encourage you to read it carefully and completely before signing this consent.

OFFICE PROCEDURES: As a part of your complimentary consultation our office will take x-rays and photographs of your teeth. This is for diagnostic purposes and will not be billed to you or your insurance company. It is near impossible for our doctors to give accurate treatment plans without these records.

USE OF RECORDS: Henseler & Kocian Orthodontics has the right to use patient photographs, x-rays, videos, and other photographic reproduction for the purpose of communication with your current and future dental and medical professionals. Our doctors also reserve the right for records obtained in our office to be used for professional, academic, patient education, and practice promotion. This includes, but is not limited to use on the Henseler & Kocian Orthodontics website, brochures, and social media sites.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices we will make available upon request a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revision of our notice, at any time by contacting:

Contact Person: Henseler & Kocian Orthodontics
Telephone: 651-739-1555
Email: schedule@hkortho.com
Address: 2850 Curve Crest Blvd., Suite 230, Stillwater, MN 55082

RIGHT TO REVOKE: You will have the right to revoke this consent at any time by giving us written notice or your revocation submitted to the contact person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation and that we may decline to treat you or to continue treating you if you revoke this consent.

SECTION C: SIGNATURE

I HAVE HAD FULL OPPORTUNITY TO READ AND CONSIDER THE CONTENTS OF THIS CONSENT FORM AND YOUR NOTICE OF PRIVACY PRACTICES. I UNDERSTAND THAT BY SIGNING THIS CONSENT FORM I AM GIVING MY CONSENT TO YOUR USE AND DISCLOSURE OF MY PROTECTED HEALTH INFORMATION TO CARRY OUT TREATMENT, PAYMENT ACTIVITIES AND HEALTH CARE OPERATIONS
PARENT/LEGAL GUARDIAN SIGNATURE:*

Clear
DATE:*

MonthDayYear
Date
Should be Empty:

Child New Patient Information

PARENT 1 INFORMATION

PARENT 2 INFORMATION

DENTAL INSURANCE INFORMATION

MEDICAL INFORMATION/HISTORY

PATIENT SURVEY

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION