BDD CHILD NEW PATIENT PACKET

BRODERICK DUSEK & DELEON

Child Patient Information
Patient's Name*

First NameMiddle InitialLast Name
Preferred Name
Date of Birth*

MonthDayYear
Date
Age
Sex*
Preferred Pronoun
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Is the Patient a Full Time Student?
Name of School Attending
Email*
example@example.com
Name of Patient's General Dentist*
Name of Patient's Primary Physician
Physician Phone Number
Please enter a valid phone number.
Who may we thank for referring you to our office?*
Is there a specific reason you are seeking Orthodontic treatment?
Have we treated any other family members?*
Family Member Name we have treated
Family member's Relationship to Patient
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact's Relationship to the Patient*
Patient's Father/Guardian Name*
Father/Guardian's Address (if different from Patient)
Father/Guardian's Main Number
Please enter a valid phone number.
Father/Guardian's Secondary Number
Please enter a valid phone number.
Father/Guardian's Date of Birth

MonthDayYear
Date
Father/Guardian's Employer
Mother/Guardian's Name
Mother/Guardian's Address (if different from Patient)
Mother/Guardian's Main Phone Number
Please enter a valid phone number.
Mother/Guardian's Secondary Phone Number
Please enter a valid phone number.
Mother/Guardian's Date of Birth

MonthDayYear
Date
Mother/Guardian's Employer
Person Financially Responsible for the Account - i.e. Parent/Guardian (Insurance cannot be the responsible party)
Name*

PrefixFirst NameLast Name
Father/Guardian's SS#
Mother/Guardian's SS#
*IF the Person Fiancially responsible is different than the Father, Mother, or Guardian (i.e Grandparent) please fill out the following:
First & Last Name
Relationship to Patient
Date of Birth

MonthDayYear
Date
Social Security #
Main Phone Number
Please enter a valid phone number.
Secondary Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Employer's Address
Employer's Phone Number
Please enter a valid phone number.
Does the patient have Orthodontic Coverage?*

YESNO
*IF YES, please fill out our Insurance form with the Subscribers information. Without this information we will not be able to verify your Orthodontic Benefits.

Privacy Consent and Patient Authorization Form

This form is required by the patient privacy regulations issued by the United Stated Department of Health and Human Services. Prior to commencing your orthodontic treatment, you must review, sign, and date this form.

Your protected health information (i.e. individually identifiable information such as names, dates, phone numbers, email addresses, and demographic data) as well as photographic and radiographic images may be used in connection with your treatment, payment of your account or health care operations. This signed form will allow us to leave appointment information, financial information or anything that might be pertinent to the patient on your cell phone. You have the right to request restrictions on the use of your protected health information.

Our office is only able to have one party be held responsible for the account. We will be happy to file insurance that is through another party. We must have a completed claim form with the insured's signature and the responsible party's signature allowing us to disclose the information to the insurance company and the insured's signature for authorization of payment.

You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent. We may amend the privacy notice at any time. If we do, we will provide you with a copy of the changes.
Patient Name *
DATE

MonthDayYear
Date
Parent/Guardian
Patient/Parent/Guardian (SIGNATURE)*

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Many of our patients allow family members such as their spouse, significant other, parents or children to call and request clinical and financial information. Under the requirements for H.I.P.P.A. we are not allowed to give this information to anyone without the responsible party's consent. If you wish to have your medical information and/or financial information released to any family members you must list them on this form.

I authorize Drs. Broderick, Dusek and DeLeon Orthodontics to release my records and any information requested to the following individuals.
1. I consent information to
1. Relationship to Patient
2. I consent information to
2. Relationship to Patient
3. I consent information to
3. Relationship to Patient
4. I consent information to
4. Relationship to Patient
Signature*

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Informed Consent Form

Please read the following carefully.
Excellent orthodontic results can only be achieved with informed and cooperative patients. While recognizing the benefits of a pleasing smile and healthy teeth, you should be aware that orthodontic treatment is not an exact science, and like any treatment of the body, has some inherent risks and limitations.

Decalcification -Permanent Tooth Discoloration - This can happen with or without orthodontic treatment. At times the cause is unknown; however, it is usually due to poor oral hygiene. Therefore, excellent oral hygiene, reduction of sugar in your diet, and reporting any loose bands or bonds as soon as detected, are a must in minimizing decalcification, decay and gum disease.

Periodontal Problems -Swollen and/or Receding Gums, Bone Loss and Tooth Mobility - Although the exact cause of some periodontal problems during orthodontic treatment is unknown, contributing factors are poor oral hygiene and general health problems. Gingival recession may occur where teeth are severely rotated or the surrounding bone is thin. Sore or swollen gums may also occur due to lack of proper brushing around the braces and gums.

Root Resorption -Shortening of Root Ends - This can occur with or without orthodontic treatment and its occurrence is unpredictable. Usually this presents no problem under normal healthy conditions; however, in extreme and unusual cases, this can affect the longevity of the teeth involved. It should also be noted that trauma, cuts, impaction, endocrine disorders, or idiopathic reasons can also cause this problem.

Nonvital or Dead Tooth -A Traumatized Tooth -Trauma to a tooth can come from a blow or deep filling. A traumatized tooth can become nonvital over a long period of time with or without orthodontic treatment. For these, or unknown reasons, teeth may become symptomatic and/or turn dark during or after orthodontic treatment and require endodontic treatment.

Impacted Teeth -Teeth Unable To Erupt Properly - These teeth have a defective path of eruption. In trying to move them or while making space for them, occasionally problems are encountered which may lead to the loss of the tooth or adjacent teeth, endodontic treatment, or periodontal problems.

Headgear -Instructions Must Be Followed Carefully - You should not engage in physical activity or games while wearing your headgear. If it is pulled out with the elastic force still attached, it can snap back and cause injury to the face or mouth.

Lack Of Patient Cooperation -Most Common Cause For Increased Treatment Time - Insufficient wearing of elastics or headgear, poor diet, broken appliances, and missed appointments are important factors that can lengthen treatment time and adversely affect the quality of results. A lack of patient cooperation in any of these areas may result in the need to remove all orthodontic appliances and discontinue treatment.

Temporomandibular Joints ( TMJ) -Sliding Hinge Joint Connecting The Upper And Lower Jaws - Jaw joint (TMJ) pain or clicking may occur at any time during one's life. Although the exact cause(s) are difficult to determine, tooth position and bite may be a factor. Orthodontic treatment may lessen or eliminate the dental causes of TMJ syndrome, but not the non-dental causes. Unfortunately, scientific evidence indicates there is no guarantee that orthodontic treatment will resolve TMJ problems.

Growth Patterns -Facial Growth During Or After Treatment - Bad habits, unusual skeletal patterns and insufficient or undesirable growth can compromise the dental results, affect a facial change and cause shifting of the teeth or bite during retention. These factors are beyond the orthodontist's control and in severe cases, surgical procedures may be recommended to treat these problems.

Post Treatment -Tooth Movement Relapse - There is a likelihood that some teeth will shift after treatment. Some of these changes are natural and may or may not be desirable. Rotations, lower anterior changes, and slight spaces in extraction sites or between the upper central incisors are the most common examples. Proper wearing of your retainers will minimize these problems; however, when retention is discontinued,. some relapse is still possible.

Unusual Occurrences-Swallowing Appliances, Chipping Teeth, Dislodging Restorations, Other _________ - This information is not intended to discourage you from having the recommended orthodontic treatment and it is unlikely that the above will be a problem in your treatment, but we do want you to be fully informed. We sincerely believe the many advantages to be gained from orthodontic treatment far outweigh these possible risks and limitations. If you have any questions about this information, please do not hesitate to discuss them with us.

I consent to the taking of photographs and x-rays before, during and after treatment, and to the use of same by the Doctors in scientific papers, demonstrations or marketing purposes. We will ask for verbal permission before any images are used for marketing purposes.
I certify that I have read or had read to me the contents of this form and that I understand the information and consent to orthodontic treatment
Patient/Parent/ Guardian Signature*

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Date

MonthDayYear
Date

DATE

MonthDayYear
Date
DENTAL INSURANCE INFORMATION ONLY
If you do not have any Dental or Orthodontic Insurance Please scroll to the bottom of this page and click on SUBMIT so that we receive the information you have already filled out. Thank you!

* As a courtesy to you, we accept assignment of insurance benefits from most insurance companies. HOWEVER, the balance is your responsibility whether your insurance company pays or not. You must make sure we have your current insurance information on file. Your insurance policy is a contract between you and your insurance company. We are not party to that contract.
Name

First NameMiddle InitialLast Name
Preferred Name
DOB
Age
PRIMARY ORTHODONTIC INSURANCE
Subscriber's Name

First NameMiddle InitialLast Name
Subscriber's Relationship to Patient

SelfSpouseParentStep Parent
Subscriber's Address

Insured's Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Subscriber's Soc. Sec. #
Subscriber's Date of Birth

MonthDayYear
Date
Subscriber's Home Phone
Subscriber's Cell Phone
Subscriber's Work Phone
Subscriber's Employer
Policy/Group#
Patient's Member ID#
Insurance Company
Effective Date of Coverage

MonthDayYear
Date
Insurance Co Address
Insurance Co. Provider Phone Number
**I authorize release of any information relating to this claim.

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** I authorize payment directly to the dentist.

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SECONDARY ORTHODONTIC INSURANCE
Name

First NameMiddle InitialLast Name
Relationship to Patient

SelfSpouseParentStep Parent
Subscriber's Address

Insured's Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Subscriber's Soc. Sec.#
Subscriber's Date of Birth

MonthDayYear
Date
Subscriber's Home Phone
Subscriber's Cell Phone
Subscriber's Work Phone
Subscriber's Employer
Policy/Group#
Patient Member ID#
Insurance Company
Effective Date of Coverage

MonthDayYear
Date
Insurance Co Address
Insurance Co Provider Phone
** I authorize release of any information relating to this claim.

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** I authorize payment directly to the dentist.

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Office Insurance Policy
As a courtesy to our patients with active dental insurance plans, we will verify your eligibly prior to starting orthodontic services with our office. Our insurance department will validate the estimated insurance credit we have given to you is the most current information provided by your insurance policy.

Please know that insurance companies do not pay for your orthodontic treatment in full upon submission of a single claim. Nor do they pay per office visit, as they do with your general dental needs. Orthodontic insurance is paid over the course of your treatment time, monthly, quarterly, or annually depending on the policy.

In order to receive the full insurance benefit we have quoted for you, this policy must remain active for the duration of your orthodontic treatment with our office. If any changes or lapse in coverage occurs during the course of treatment, your insurance reserves the right to stop any additional payments on this treatment.

Please note that we only collect payment from one insurance carrier per orthodontic treatment. If you have dual coverages, we will be delighted to file with your secondary payer on your behalf. However, we will require them to send any payments to you directly for your treatment. This clause also applies with coverages obtained after you have already started orthodontic treatment with our office. In addition, we only file insurance for patients in active orthodontic treatment. Insurance claims for lost or broken retainers will not be filed by our office.

If for any reason your insurance declines to pay the estimated portion of your orthodontic treatment, you are liable for the unpaid balance prior to the removal of your orthodontic appliances.
Name of Responsible Party

First NameLast Name
Signature

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Date

MonthDayYear
Date
Should be Empty:

BRODERICK DUSEK & DELEON

Medical History

Informed Consent Form

DENTAL INSURANCE INFORMATION ONLY

PRIMARY ORTHODONTIC INSURANCE

SECONDARY ORTHODONTIC INSURANCE

Office Insurance Policy