PATIENT FORM

PATIENT INFORMATION

www.engortho.com | info@engortho.com | 303 498-0351 | 970 542-2500

Patient’s Name

Date

Sex

Male Female

Address

City

State

Zip Code

Home phone

Birthday

Age

SSN

Dentist

School

Grade

Children/Siblings:

Mention all of child/siblings Name(s), Birthday(s), Age(s), School(s):

Friends seen in our office

Whom may we thank for referring you to our office?

Top reasons why I chose Eng Orthodontics

EMERGENCY CONTACT

Emergency Contact Name

Emergency Contact #

Relationship to Patient

Address

City

State

Zip Code

Phone

Email address

The office reserves the right to verify the credit status of potential patients seeking payment terms.

Signature

Date

RESPONSIBLE PARTY INFORMATION

Self/Parent/Guardian

Relationship to Patient

SSN

Birthday

Employer

Occupation

Years employed

Work Phone

Residence Address

City

State

Zip Code

Mailing address

City

State

Zip Code

How long at this address?

Home phone

Email Address

Cell/Other Phone

Previous Address (if less than 3 years)

Self/Parent/Guardian

Relationship to Patient

SSN

Birthday

Employer

Occupation

Years employed

Work Phone

Residence Address

City

State

Zip Code

Mailing address

City

State

Zip Code

How long at this address?

Home phone

Email Address

Cell/Other Phone

Previous Address (if less than 3 years)

Person financially responsible for this account

DENTAL INSURANCE INFORMATION

Insured’s Name

Birthday

Employer Name

Employer Address

City

State

Zip Code

Insured’s SSN

ID#

Insurance Company

Group No

Local No

Insurance Company Address

City

State

Zip Code

Phone

Do you have dual coverage? (If yes, please complete information below.)

Yes No

Insured’s Name

Birthday

Employer Name

Employer Address

City

State

Zip Code

Insured’s SSN

ID#

Patients First Name

Patients Last Name

MEDICAL HISTORY

Physician

Date of last visit

Address

City

State

Zip Code

Phone

Please select Yes or No (If yes, please fill in the details)

Are you taking any medications?

Yes No

Medications Detail.

Are you allergic to any medication?

Yes No

Allergic Medications Detail.

Do you have a history of a major illness?

Yes No

Major Illness Detail.

Have you had any operations?

Yes No

Operations Detail.

Have you ever been involved in a serious accident?

Yes No

Operations Detail.

Have you seen a physician in the last 12 months? Why?

Yes No

Operations Detail.

Any other medical conditions, sensory issues or other special needs that you feel we should be aware of

DENTAL HISTORY

Dentist

Date of last visit

Address

City

State

Zip Code

Phone

What concerns you about your teeth?

Are you presently in any dental pain?

Yes No

If yes, please describe

Have you ever experienced any unfavorable reaction to dentistry?

Yes No

If yes, please describe

Have you ever lost or chipped any teeth?

Yes No

If yes, please describe

Have there been any injuries to face, mouth, or teeth?

Yes No

If yes, please describe

Is any part of your mouth sensitive to pressure or temperature? Where?

Yes No

If yes, please describe

Do your gums bleed when you brush?

Yes No

If yes, please describe

Do you have any type of thumb or tongue habit?

Yes No

If yes, please describe

Are you a mouth breather?

Yes No

If yes, please describe

Have you ever seen an orthodontist? If yes, who and when?

Yes No

What is your attitude toward receiving orthodontic treatment?

Has anyone in your family received orthodontic treatment?

Yes No

How did they feel about the result?

Do your teeth or jaws ever feel uncomfortable when you wake up in the morning?

Yes No

If yes, please describe

Are you aware of your jaw clicking or popping?

Yes No

If yes, please describe

Are you aware of clenching or grinding your teeth?

Yes No

If yes, please describe

Do you have “tension” headaches?

Yes No

If yes, please describe

Are you aware that some appointments will be during school/work hours?

Yes No

If yes, please describe

Please list hobbies or interests

Female Patients Only

Are you pregnant?

Yes No

Has menstruation started?

Yes No

I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history.

Patient First Name

Patient Last Name

Authorization for Use and Disclosure of Protected Health Information

COMPLETE ONLY IF ENG ORTHODONTICS MAY SHARE PATIENT INFORMATION WITH OTHERS SUCH AS STEPPARENTS, GRANDPARENTS, SPOUSE, FRIENDS, ETC. IF THERE IS NO ONE YOU WOULD LIKE TO SHARE YOUR INFORMATION WITH, LEAVE BLANK AND SIGN BOTTOM LINE.

Patient's Name

Patient's DOB

Address

l hereby authorize Eng Orthodontics to release information, as indicated below, to the following person(s) listed below.

Authorized persons name

Relationship to the patient

Phone number

Permission to release all clinical information?

Yes No

Permission to release all financial information?

Yes No

I authorize Eng Orthodontics to contact the individual(s) listed above to convey information as listed above regarding the patient in the event that I am unable to be reached by Eng Orthodontics.

I understand that I may revoke/cancel this authorization by notifying Eng Orthodontics, in writin , of my intent to revoke authorization, or change the name(s) of those listed to whom the information is to be released.

Please note that if the patient is under the age of 18, a legal guardian must either be present during the initial consultation or must have this page filled out with the name of the individual(s) bringing the patient to the exam.

Signature of Patient (OR legal guardian if the patient is under 18 of age)

Date

PRIVACY POLICY

This policy describes how medical/dental information about you may be used and disclosed and how you can get access to this information. Please read it carefully.

We understand that the privacy of your personal information is important to you. As your orthodontic office, we believe your right to privacy is a fundamental part of your treatment; as such, we want you to understand our privacy practices and procedures. Should you have any questions regarding these policies please do not hesitate to contact our office at (303)498-0351.

Information We Collect About You

We collect personal information about you and your family as part of our new patient process, during the course of your care, and from other health care entities you utilize, such as; other dentists and specialists, imaging facilities, laboratories, and your insurance company. This personal information includes items such as your name, address, phone number, birth date, social security number, employer, health history, insurance policy and coverage information and any information you provide. During the course of your treatment we will collect dental information regarding diagnosis, treatment plans, progress and any test results or films.

How Your Information Is Used

The personal and health information gathered may be used and disclosed with your general consent for purposes of treatment, payment, or routine health care operations. This means we may send your information to other dentists or facilities involved in your treatment as well as to your insurance company or a collection agency to obtain payment. This includes electronic submission of your information for insurance claim purposes. This also includes contact with you and your family to provide appointment reminders or information about treatment. Any other uses of your information require a signed authorization by you, the patient or guardian and can be revoked at any time with a written request. Eng Orthodontics does not sell patient information to any third party. In certain cases of public health interest we may be required to disclose certain information to local, state, or national health organizations or government agencies.

Safeguarding Your Personal and Health Information
We are required by law to (1) make sure that medical information that identifies you is kept private, (2) provide you with our privacy policy, and (3) follow the terms laid out in the privacy policy. As a means of protecting your privacy, we restrict access to your personal and health information only those employees who require the information to complete their jobs and provide quality service to you.

Eng Orthodontics maintains physical, electronic, and procedural safeguards to comply with state and federal regulations that guard your personal and health information. If you feel your privacy has been violated you have the right to file a complaint with the
Department of Health and Human Services. A complaint in no way will influence with your course of treatment with our office.

Changes to Our Privacy Policy
All new patients will review a copy of our privacy policy. Eng Orthodontics occasionally reviews the Privacy Policy and reserves the right to amend it. Notification of changes will be available at the front desk prior to the effective date of any changes.

Right to Restrict Use of Information

You have the right to request restrictions to our uses or disclosures of your personal or health informatio, although we are not required to agree to those restrictions. Once your request has been processed it will remain in effect until you request a change.

Patient Acknowledgement

I have reviewed Eng Orthodontics Privacy Policy and understand that my diagnostic records and my name may be used for educational and promotional purposes.

Signature

Date

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