Patient Information

Patient's Name

Address

City

State

Zip Code

Home Phone No.

Birthdate

Social Security No.

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

Whom may we thank for referring you to our office?

Responsible Party Information

Name

Marital Status

Residence

City

State

Zip

Mailing Address

City

State

Zip

How long at this address

Email address

Previous Address (if less than 3 years.)

Home Phone No.

Work Phone No.

Cell Phone No.

Social Security No.

Birthdate

Relationship to Patient

Employer

Occupation

No. of Years Employed

Spouse's Name

Relationship to Patient

Employer

Occupation

No. of years Employed

Social Security No.

Birthdate

Work Phone No.

Insurance Information

Insured's Name

Insured's Soc. Sec No.

Insurance Company

Group No.

Local No.

Insurance Co. Address

Insured's Employer

Emergency Information

Name of nearest relative not living with you

Phone No.

Complete Address

I understand that where appropriate, credit bureau reports may be obtained.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature (Parent's Signature if Minor)

Date

Medical History

If yes, Please list

Does patient have tendency to

Colds

Sore throats

Ear infections

Does the patient use any tobacco products?

Please specify

List any drugs or medications now being taken (give reason)

List any allergies or drug sensitivity

Patient's Physicians

Dental History

If yes, until what age?

While awake?

While Asleep?

Patient's General Dentist

City

Phone No.

Last Cleaning

Is there any additional information you would like us to be aware of?

Siblings Names and Ages

Acknowledgement of Receipt of Notice of Privacy Practices

*You May Refuse to Sign This Acknowledgement*

have received a copy of this office's Notice of Privacy Practices.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Name / Signature

Date

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to sign

Communications barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Other (please specify below)

Your information will be encrypted.

Patient Information

Responsible Party Information

Insurance Information

Emergency Information

Medical History

Dental History

Acknowledgement of Receipt of Notice of Privacy Practices

Brieden Orthodontics