NEW PATIENT PAPERWORK
DATE:
NAME :
LAST NAME
FIRST NAME
MIDDLE INITIAL
PATIENT PREFERRED NAME:
DOB:
ADDRESS:
APT/UNIT #:
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:
CONTACT PHONE NUMBER:
DENTAL INSURANCE
INS COMPANY:
MEMBER #:
GROUP #:
SUBSCRIBER NAME:
SUBSCRIBER SSN:
SUBSCRIBER DOB:
MY RELATIONSHIP TO SUBSCRIBER:
SELF
SPOUSE
CHILD
OTHER
DENTAL/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.)?
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?
9 S 9
TH
STREET, SUITE 5, NASHVILLE, TN 37206 | 615.420.2742 | ELEVATIONORTHODONTICS.COM
NAME OF GENERAL DENTIST:
NAME OF ORAL SURGEON (IF APPLICABLE):
LIST ANY FACE, MOUTH OR TEETH INJURIES?
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
BRACES
NO PREFERENCE
WHEN DO YOU WANT TO START TREATMENT?
ASAP
WITHIN THE MONTH
WITHIN THE YEAR
WHAT IS YOUR BARRIER TO STARTING TREATMENT?
FINANCES
SCHEDULE
DENTAL ANXIETY
HOW DO YOU PLAN ON PAYING FOR TREATMENT?
IN FULL
MONTHLY PAYMENTS
3
RD
PARTY
APPOINTMENT RESERVATION POLICY
TO RESERVE YOUR COMPLIMENTARY CONSULTATION, E|O REQUIRES A CREDIT CARD ON FILE. THIS CARD IS USED SOLELY TO HOLD YOUR APPOINTMENT TIME. YOU WILL NOT BE CHARGED UNLESS YOU FAIL TO ATTEND YOUR CONSULTATION OR CANCEL/RESCHEDULE WITH LESS THAN 24 HOURS’ NOTICE, IN WHICH CASE A $25.00 FEE WILL BE CHARGED. BY PROVIDING YOUR CREDIT CARD INFORMATION, YOU UNDERSTAND AND AGREE TO THE ABOVE POLICY.
CREDIT CARD NO:
EXP DATE:
CVV CODE:
PATIENT CONSENT + DISCLOSURES
I AUTHORIZE E|O TO PERFORM DIAGNOSTIC PROCEDURES AS DEEMED NECESSARY FOR ORTHODONTIC EVAULATION AND TREATMENT PLANNING. I UNDERSTAND ORTHODONTIC TREATMENT OUTCOMES CANNOT BE GUARANTEED AND THAT TREATMENT PLANS, FEES AND TIMELINES MAY CHANGE BASED ON CLINICIAL FINDINGS OR PATIENT COMPLIANCE.
I CONSENT TO RECEIVE COMMUNICATIONS FROM THE OFFICE BY PHONE, EMAIL AND/OR TEXT REGARDING APPOINTMENTS, TREATMENT, BILLING AND PRACTICE-RELATED INFORMATION.
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
I CERTIFY THAT THE INFORMATION I HAVE PROVIDED ON THIS FORM IS ACCURATE AND I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS. I ACKNOWLEDGE THAT I HAVE REVIEWED AND UNDERSTAND THE INFORMATION PROVIDED IN THIS NEW PATIENT PAPERWORK.
PATIENT SIGNATURE
Date:
9 S 9
TH
STREET, SUITE 5, NASHVILLE, TN 37206 | 615.420.2742 | ELEVATIONORTHODONTICS.COM