Patient Information Form

Patient's First Name

Patient's Last Name

Nickname

Patient's Address

City

State

Zip

Interests/Sports/Hobbies

Home Phone No.

Date of Birth

Age

Race

Cell Phone No.

School/Employer

Grade/Position

Work Phone

How did you hear about our office

Email address

Family members treated in our office

Reason for consultation

Dentist

Date of last cleaning

RESPONSIBLE PARTY/ INSURANCE INFORMATION

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RESPONSIBLE PARTY 2 / INSURANCE INFORMATION

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SLEEP/ AIRWAY ISSUES

DENTAL/MEDICAL HISTORY

What?

If yes, which tooth/teeth?

Due Date?

If yes, when?

List

If yes, list here:

Please check if the patient has, or ever had, any of the following habits?

Cheek, tongue or lip chewing

Tongue sucking

Clenching teeth

Thumb sucking

Finger nail biting

Tongue thrusting

Grinding teeth

SIGNED CONSENT

I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status.

I hereby authorize this office to perform an orthodontic evaluation and consent to the taking of x-rays, photographs, and other records (if necessary) to determine appropriate treatment on the above-named patient.

I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.

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.

Name/Signature

Relationship to Patient

Date

If someone other than the parent(s) or guardian(s) listed above will be bringing the patient to appointments, please list here:

HIPAA Patient Consent

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (a.k.a HIPAA or the Healthcare Privacy Act). I understand that by signing this consent, I authorize This Office to use and/ or disclose my protected healthcare information to carry out the following:

- Treatment which includes direct and/ or indirect treatment by my other healthcare providers involved in my treatment.

- Obtaining payment from third party payers, i.e. my dental and/or medical insurance company/ companies.

- The day to day healthcare operations of your dental practice.

I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses of disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may request the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and healthcare operations, but that you are not required to agree to use these requested restrictions. However, if you do not agree, you are bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent will not be affected.

Patient Name / Signature