PATIENT INFORMATION
Date
Patient's Name
Last
First
Middle
Address
Street
City
Zip
Nickname
DOB
Sex
M
F
Home Phone #
Cell Phone #
Email Address
Marital Status
RESPONSIBLE PARTY INFORMATION
Name
Occupation
DOB
Employed by
SS#
Spouse Name
Occupation
DOB
Employed by
SS#
*all office correspondence will go to address where patient resides
Whom may we thank for referring you?
DENTAL INSURANCE INFORMATION
For those patients with orthodontic coverage
Subscriber's Name
Subscriber ID#
Subscriber DOB
Employer Name
Group#
Insurance Company
Insurance Address
Street
City
State
Zip
Do you have dual coverage?
No
Yes
if yes please notify front desk staff
MEDICAL HISTORY
Physician
Date of Last Visit
Address
Phone#
Please circle yes or no (if yes please fill in details):
Yes
No
Is the patient taking any medication?
Yes
No
Is the patient allergic to any medication?
Yes
No
Is the patient allergic to any materials?
Yes
No
History of major illness or operations?
Yes
No
Ever been involved in a serious accident?
Yes
No
Have seen a physician in last 12 months? Why?
Female Patients only:
Circle any of the medical conditions below that the patient has had or currently has:
Abnormal bleeding/Hemophilia
Hepatitis/Liver problems
Anemia
Herpes
Arthritis
High Blood Pressure
Asthma or Hayfever
HIV/AIDS
Bone Disorders
Kidney Problems
Congenital Heart Defect
Nervous Disorders
Diabetes
Pneumonia
Dizziness
Prolonged Bleeding
Epilepsy
Radiation/Chemotherapy
Gastrointestinal Disorders
Tuberculosis
Heart Problems
Tumor
Heart Murmurs.....Pre-med needed?
Cancer
***Are there any medical conditions we have not discussed that you feel we should be aware of or does patient require antibiotics prior to dental treatments?
DENTAL HISTORY
General Dentist
Date of Last Visit
What concerns you most about your teeth?
Yes
No
Is the patient currently in any dental pain?
Yes
No
Ever experienced any unfavorable reaction to dentistry?
Yes
No
Has the patient ever lost or chipped any teeth?
Yes
No
Have there been any injuries to the face, mouth, or teeth?
Yes
No
Is any part of your mouth sensitive to temperature? Where?
Yes
No
Do gums bleed when brushing?
Yes
No
Any type of finger or thumb habit?
Yes
No
Is the patient a mouth breather?
Yes
No
Has the patient ever seen an orthodontist?
What is the patient's attitude toward receiving orthodontic treatment?
Has anyone in the family received orthodontic treatment?
Yes
No
Experience jaw clicking or popping?
Yes
No
Aware of clenching or grinding teeth during the day?
Yes
No
Experience "tension headache?"
Yes
No
Has the patient ever had chronic ringing in the ears?
Yes
No
Does the patient need extra help with instructions?
Yes
No
Is the patient sensitive or self-conscious about their teeth?
BENEFITS
Benefits of orthodontics: Aesthetics, health and function. Orhtodontics is a serivce that provides improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part 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 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 Coastal Orthodontics to perform an orthodontic evaluation.
Signature:
Date:
CONSENT FOR TREATMENT
As patient or guardian, I understand that all proposed treatment will be explained to me prior to being performed. I consent to Coastal Orthodontics and staff providing orthodontic treatment to myself.
Signature:
Date:
ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES - HIPAA
I am aware of the Notice of Privacy Practices.
Signature:
Date:
I consent to Coastal Orthodontics using my cell phone for phone calls, appointment reminders, questions regarding treatment, insurance and my account. Phone calls, voicemails and texting may not always be 100% secure depending on the mobile service you use. I understand
that I can withdraw my consent at any time. My current cell phone number is:
Initials:
SUPPLEMENTAL INFORMED CONSENT
Orthodontic Treatment in the Era of COVID-19
Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “Coronavirus,” at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so. Although exposure is unlikely, you accept the risk and consent to treatment
Signature
(Date)
MEDICAL HISTORY UPDATE
PATIENT'S NAME:
Date:
No Change
Change
Signature
Notice of Privacy Practices (NPP)
Dental Practice Name: Coastal Orthodontics
Effective Date: 04/17/2025
Our Commitment to Your Privacy
We are committed to protecting the privacy of your health information. This Notice of Privacy Practices explains how we may use and disclose your health information, as well as your rights regarding this information. Please review it carefully.
How We May Use and Disclose Your Health Information Treatment
We may use your health information to provide, coordinate, or manage your care. This may include sharing it with other healthcare providers.
Payment
We may use your information to obtain payment for the services we provide to you.
Healthcare Operations
We may use your information for quality assurance, training, and customer service purposes.
Appointment Reminders
We may contact you to remind you of appointments by phone, email, or mail.
Fundraising
We may contact you for fundraising activities, but you have the right to opt out.
Other Permitted and Required Disclosures
- Required by Law:
We may disclose your information as required by federal, state, or local laws.
- Public Health:
We may disclose information for public health activities.
- Abuse, Neglect, or Domestic Violence:
We may disclose information to appropriate authorities if we suspect abuse or neglect.
- Health Oversight Activities:
We may disclose information for audits and investigations.
- Legal Proceedings:
We may disclose information in response to a court order.
- Law Enforcement:
We may disclose information to law enforcement in certain situations.
Your Rights Regarding Your Health Information
Right to Access
You can inspect and copy your health information. Fees may apply for copies.
Right to Amend
If you believe your information is incorrect or incomplete, you may request an amendment.
Right to an Accounting of Disclosures
You may request a list of certain disclosures we made of your health information.
Right to Request Restrictions
You can request limits on how we use or disclose your information. We will consider your request but are not required to agree.
Right to Confidential Communications
You can request we communicate with you at a specific location or by a certain method.
Right to a Paper Copy of This Notice
You have the right to request a paper copy of this Notice at any time.
Changes to This Notice
We reserve the right to change this Notice and apply those changes to all information we maintain. We will post a copy of the current Notice in our office and on our website.
Questions and Complaints
If you have questions about this Notice or believe your privacy rights have been violated, you may contact:
You may also file a complaint with the U.S. Department of Health and Human Services. Filing a complaint will not affect the quality of care you receive.
Acknowledgment of Receipt of Notice of Privacy Practices
By signing below, you acknowledge that you have received a copy of this Notice of Privacy Practices.
Patient Acknowledgment
I acknowledge that I have received a copy of the Notice of Privacy Practices.
Patient Name (Print)
Signature
Date