CHILD HEALTH HISTORY

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

Phone

Birthday

Age

School

Parent/ Guardian Information:

Patient lives with:

Both Parents Mother Father Other

Guardian 1

Relationship to Patient

Employer

Cell #

Guardian 2

Relationship to Patient

Employer

Cell #

Address (if different from patient)

City

State

Zip

Email address

Language spoken

Friends/ Family seen in our office

Whom may we thank for referring you to our office?

DENTAL INSURANCE INFORMATION

Insurance Company Name

Phone Number

Insurance Company Address

City

State

Zip Code

Employer Name

Group No

Subscriber ID#

Policy Holder Name

Policy Holder SSN

Policy DOB

(If you have dual coverage, please complete information below)

Insurance Company Name

Phone Number

Insurance Company Address

City

State

Zip Code

Employer Name

Group No

Subscriber ID#

Policy Holder Name

Policy Holder SSN

Policy DOB

We are committed to providing you with the best possible care. If you have dental insurance, we are eager to help you receive your maximum allowable benefits. To achieve these goals, we need your assistance and understanding of our payment policy.

Payment for services is due at the time services are rendered unless payment arrangements have been approved in advance by our staff. We accept cash, check, Master Card, Visa and Discover. Returned checks and balances older than 30 days may be subject to additional collection fees of $30 per month. We will gladly assist you by submitting all insurance claims pertaining to charges for care rendered in our office. It is your responsibility to make sure we have the most current and up to date insurance information including any secondary insurance policies.

We must emphasize that as a dental care provider, our relationship is with our patients and their families and not with their respective insurance companies. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered. We realize that temporary financial problems may affect timely payments of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. If you have any questions about the above information or any uncertainty regarding insurance coverage, please do not hesitate to ask us. We are here to help you!

I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance on my account for any professional services rendered.

Signature

Date

MEDICAL HISTORY

Physician

Phone

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

Does this patient now or have they ever taken bisphosphonates, including Fosamax, Didronel, Boniva, Aredia, Actonel, Skelid, or Zometa?

Yes No

If yes, write details

Is the patient taking any medications at this time?

Yes No

If yes, write details

Does the patient have any allergies to medication?

Yes No

If yes, write details

(If female) has the patient begun menstruation?

Yes No

What age?

(If female) Are you pregnant?

Yes No

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

What concerns you about your child teeth?

Does your child have, or have they previously had any of the following?

Tongue Thrust

Yes No

Sore/Bleeding Gums

Yes No

Adult Tooth Extraction

Yes No

Missing Adult Teeth Difficult Chewing

Yes No

Difficult Chewing

Yes No

Jaw pain

Yes No

Tooth Sensitivity

Yes No

Previous Orthodontic Treatment

Yes No

Clicking or Popping of Jaw

Yes No

Head/Neck, Jaw or Tooth injury

Yes No

Extra Adult teeth

Yes No

Fear of Dental Work

Yes No

Clenching or Grinding

Yes No

Finger or lip sucking habit

Yes No

Chronic Mouth Breather

Yes No

I acknowledge that the above information is correct and agree to inform the office of any changes that occur after this date. In addition, I authorize Dr. Albert Eng and Associates to perform a complete orthodontic evaluation.

Guardian Name

Relationship to Patient

Guardian Signature

Date

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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