Health-History-Form | Bell Orthodontics

Thank you for selecting our office for your comprehensive orthodontic needs! it is our goal to provide you with the best possible care. To help us meet all of your needs, please fill out this form completely. Thank you!

Patient Information

Name:

Birthdate :

Home Phone :

Address:

City :

State :

Zip :

If student, Name of school:

Male Female

Spouse or Parents' Names:

Marital Status (if patient is a minor, please give parents' status):

Single

Married

Divorced

Widowed

Whom may we thank for referring you?

Have we treated any of your family members?

Family e-mail address

Responsible Party

Name of Person Responsible for this Account :

Relationship :

Address:

City :

State :

Zip :

Social Security # :

Home Phone :

Cell Phone :

E-mail :

Name of Person Responsible for this Account :

Relationship :

Address:

City :

State :

Zip :

Social Security # :

Home Phone :

Cell Phone :

E-mail :

Dental Insurance Information

Name of Card Holder :

Relationship :

Birthdate :

Social Security # :

Ins Effective Date :

Name of Employer :

Union or Local #

Work Phone :

Address of Employer:

City :

State :

Zip :

Insurance Company :

Group#

Policy/ID#

Ins Co Address:

City :

State :

Zip :

Ins Co Phone :

Lifetime Maximum:

Percent :

If you have additional dental insurance, please complete the following:

Name of Card Holder :

Relationship :

Birthdate :

Social Security # :

Ins Effective Date :

Name of Employer :

Union or Local #

Work Phone :

Address of Employer:

City :

State :

Zip :

Insurance Company :

Group#

Policy/ID#

Ins Co Address:

City :

State :

Zip :

Ins Co Phone :

Lifetime Maximum:

Percent :

Please list the names of any brothers or sisters (or children)

Name :

Age :

Name :

Age :

Name :

Age :

Name :

Age :

Consent Form

By clicking this box you are confirming that you understand this consent form.

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 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out: • Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment); • Obtaining payment from third party payers (e.g. my insurance company);• The day-to-day healthcare operations of your 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 and 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 contact you at any time to obtain 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 health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then 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 is not affected.

By typing your name you are submitting your electronic signature*

Signature

By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

Patient Information

Responsible Party

Dental Insurance Information

Patient Medical History

Patient Dental History

Consent Form