Adult Patient Information

Your Legal Name:

Date of Birth

Preferred Name

Past/present family in treatment at our office?

Email address

Work Phone No.

Street Address

Street Address Line 2

City

State

Zip Code

Employer

Occupation

PATIENT SURVEY

Why Are You Seeking Orthodontic Treatment?

Whom May We Thank For Referring You To Our Office?

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DENTAL / MEDICAL INFORMATION HISTORY

Dentist

Last Cleaning

Physician's Name

Last Exam

PLEASE CHECK ALL THAT APPLY

WATER IS FUORIDATED

FLOSSES DAILY

TAKES FUORIDE SUPPLEMENT

BRUSHES AT LEAST TWICE DAILY

GUMS BLEED

N/A

CURRENTLY, TAKING OR EVER TAKEN A BISPHOSPHONATE? INCLUDES ANY MEDICATION USED TO MAKE BONES STRONGER, SUCH AS:

BONIVA

ACTONEL

FOSAMAR

N/A

OTHER

LIST MEDICATIONS CURRENTLY TAKING AND REASON

PLEASE LIST ANY SERIOUS MEDICAL PROBLEMS YOU HAVE EXPERIENCED

EMERGENCY INFORMATION

EMERGENCY CONTACT

RELATIONSHIP

PHONE NUMBER

Please enter a valid phone number.

Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are intricate body parts and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition,

I authorize Dr. to perform a complete orthodontic evaluation.

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

Date

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

SECTION A: PARENT/LEGAL GUARDIAN GIVING CONSENT

PATIENT LEGAL NAME

SECTION B: TO THE PATIENT - PLEASE READ THESE STATEMENTS CAREFULLY

PURPOSE OF CONSENT: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations.

COMMUNICATION: Reston Orthodontics reserves the right to communicate with the responsible party via text/e-mail regarding patient's treatment and finances. It is your responsibility to let us know if you would like to opt out of this feature.

NOTICE OF PRIVACY PRACTICES: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activities and healthcare operations of the uses and disclosures we may make of your protected health information and of other important matters about your protected health information. A copy of our notice is available upon request with this consent. We encourage you to read it carefully and completely before signing this consent.

OFFICE PROCEDURES: As a part of your complimentary consultation our office will take x-rays and photographs of your teeth. This is for diagnostic purposes and will not be billed to you or your insurance company. It is near impossible for our doctors to give accurate treatment plans without these records.

USE OF RECORDS: Reston Orthodontics has the right to use patient photographs, x-rays, videos, and other photographic reproduction for the purpose of communication with your current and future dental and medical professionals. Our doctors also reserve the right for records obtained in our office to be used for professional, academic, patient education, and practice promotion. This includes, but is not limited to use on the Reston Orthodontics website, brochures, and social media sites.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices we will make available upon request a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revision of our notice, at any time by contacting:

Telephone: 703-939-8000
Email: info@restonortho.com

RIGHT TO REVOKE: You will have the right to revoke this consent at any time by giving us written notice or your revocation submitted to the contact person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation and that we may decline to treat you or to continue treating you if you revoke this consent.

SECTION C: SIGNATURE

I HAVE HAD FULL OPPORTUNITY TO READ AND CONSIDER THE CONTENTS OF THIS CONSENT FORM AND YOUR NOTICE OF PRIVACY PRACTICES. I UNDERSTAND THAT BY SIGNING THIS CONSENT FORM I AM GIVING MY CONSENT TO YOUR USE AND DISCLOSURE OF MY PROTECTED HEALTH INFORMATION TO CARRY OUT TREATMENT, PAYMENT ACTIVITIES AND HEALTH CARE OPERATIONS

Signature

Date

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