NEW PATIENT PAPERWORK
DATE:
NAME :
LAST NAME
FIRST NAME
MIDDLE INITIAL
PATIENT PREFERRED NAME:
DOB:
ADDRESS:
CITY:
STATE:
ZIP CODE:
SEX:
M
F
SSN:
MARITAL STATUS:
PHONE NUMBER:
PHONE SERVICE CARRIER:
EMAIL ADDRESS:
HOW DID YOU HEAR ABOUT US?
FAMILY/FRIEND
SOCIAL MEDIA
DENTIST
INSURANCE
OTHER
EMERGENCY CONTACT
FULL NAME:
RELATIONSHIP:
ADDRESS:
CONTACT PHONE NUMBER:
DENTAL INSURANCE INFORMATION
PRIMARY INSURANCE:
POLICY NO.:
GROUP NO.:
SUBSCIBER NAME:
SUBSCRIBER SSN:
SUBSCRIBER DOB:
RELATIONSHIP TO PATIENT:
SELF
SPOUSE
CHILD
OTHER
INSURANCE COMPANY:
MEDICAL HISTORY
PLEASE CIRCLE YES OR NO (IF YES, PLEASE FILL IN DETAILS)
YES
NO
ARE YOU CURRENTLY TAKING ANY MEDICATIONS?
YES
NO
DO YOU HAVE A LATEX ALLERGY?
YES
NO
DO YOU HAVE A NICKLE ALLERY?
YES
NO
DO YOU SMOKE/USE TOBACCO PRODUCTS (VAPE, CIGARS, ETC.)?
LIST ANY FACE, MOUTH OR TEETH INJURIES?
9 S 9
TH
STREET, SUITE 5, NASHVILLE, TN 37206 | 615.420.2742 | ELEVATIONORTHODONTICS.COM
DENTAL HISTORY
PLEASE CIRCLE YES OR NO (IF YES, PLEASE FILL IN DETAILS)
YES
NO
HAVE YOU PREVIOUSLY HAD AN ORTHO CONSULT?
YES
NO
DO YOU CLINCH/GRIND YOUR TEETH?
YES
NO
ARE YOU EXPEREINCING JAW PAIN CURRENTLY?
NAME OF GENERAL DENTIST:
NAME OF ORAL SURGEON (IF APPLICABLE):
HOW FREQUENT ARE YOUR DENTAL CHECK-UPS?
2X YEARLY
1X YEARLY
RARELY GO
NEVER
HOW OFTEN DO YOU BRUSH/FLOSS?
DAILY
2X DAILY
4X OR MORE DAILY
RARELY
NEVER
WHAT TREATMENT ARE YOU INTERESTED IN?
INVISALIGN
INBRACE
BRACES
NO PREFERENCE
WHEN DO YOU WANT TO START TREATMENT?
ASAP
WITHIN THE MONTH
WITHIN THE YEAR
WHAT ARE YOUR BARRIERS TO STARTING TREATMENT?
FINANCES
SCHEDULE
DENTAL ANXIETY
HOW DO YOU PLAN ON PAYING FOR TREATMENT?
IN FULL
MONTHLY PAYMENTS
3
RD
PARTY
PATIENT CONSENT + DISCLOSURES
I CERTIFY TO THE BEST OF MY KNOWLEDGE THAT ALL ANSWERS HAVE BEEN FILLED IN TRUTHFULLY ANDAGREE TO INFORM THIS OFFICE OF ANY CHANGES IN MY INFORMATION.
I HEREBY GIVE PERMISSION TO ELEVATION ORTHODONTICS AND THEIR CLINICAL STAFF TO TAKE ANY RADIOGRAPHS, PHOTOGRAPHS, AND/OR STUDY MODELS DEEMED NECESSARY TO ALLOW COMPLETE DIAGNOSIS AND TREATMENT PLANNING. IN ALL CASES, I AM RESPONSIBLE FOR PAYMENT OF MY ACCOUNT. ELEVATION ORTHODONTICS WILL FILE A CLAIM TO THE PATIENT’S INSURANCE COMPANY WHEN NECESSARY. I HEREBY AUTHORIZE AND ASSIGN APPLICABLE INSURANCE BENEFITS TO BE PAID DIRECTLY TO DR. BRICE. I AUTHORIZE THE RELEASE OF MY INFORMATION NECESSARY TO PROCESS INSURANCE CLAIMS.
PATIENT SIGNATURE
Date:
SOCIAL MEDIA / PHOTO CONSENT FORM
ELEVATION ORTHODONTICS WOULD LIKE YOUR PERMISSION TO USE IMAGES TAKEN IN OFFICE TO SHOWCASE ELEVATED BEFORE AND AFTER SMILES ON OUR WEBSITE, SOCIALS AND OTHER IN-OFFICE MATERIALS. PLEASE INDICATE BELOW IF YOU CONSENT TO THE USE OF YOUR PICTURES:
I GRANT PERMISSION FOR PICTURES OF ME/MY SMILE TO BE USED BY E|O
I
DO NOT
GRANT FOR PICTURES OF ME/MY SMILE TO BE USED BY E|O
PATIENT/PARENT OR GUARDIAN SIGNATURE
Date:
9 S 9
TH
STREET, SUITE 5, NASHVILLE, TN 37206 | 615.420.2742 | ELEVATIONORTHODONTICS.COM