NEW PATIENT PAPERWORK
Date
PATIENT NAME :
LAST NAME
FIRST NAME
MIDDLE INITIAL
PATIENT PREFERRED NAME:
ADDRESS:
HOME PHONE:
WORK PHONE:
CELL PHONE:
CELL PHONE PROVIDER:
SEX:
M
F
BIRTHDATE:
AGE:
SSN:
EMAIL ADDRESS:
MAY WE CONTACT YOU BY EMAIL?
Y
N
MARITAL STATUS:
SPOUSE’S NAME (if applicable):
How did you hear about our practice?
EMERGENCY CONTACT INFORMATION
NAME :
ADDRESS:
PHONE NUMBER:
RESPONSIBLE PARTY INFORMATION
CHECK HERE IF PATIENT IS RESPONSIBLE PARTY
NAME :
LAST NAME
FIRST NAME
MIDDLE INITIAL
ADDRESS:
PHONE NUMBER:
RELATIONSHIP TO PATIENT:
SEX:
M
F
BIRTHDATE:
AGE:
SSN:
9 S 9th Street, Nashville, TN 37206 | 615-420-2742 (P) | elevationorthodontics.com
DENTAL INSURANCE INFORMATION
PRIMARY INSURANCE:
GROUP NO.:
INS. ADDRESS:
INS. PHONE:
INSURED’S NAME:
INSURED’S SSN:
INSURED’S RELATIONSHIP TO PATIENT
SELF
SPOUSE
CHILD
OTHER:
SECONDARY INSURANCE:
GROUP NO.:
INS. ADDRESS:
INS. PHONE:
INSURED’S NAME:
INSURED’S SSN:
INSURED’S RELATIONSHIP TO PATIENT:
SELF
SPOUSE
CHILD
OTHER:
DENTAL HISTORY
CIRCLE IF PATIENT HAS (OR PREVIOUSLY HAVE) EXPERIENCED ANY OF THE FOLLOWING:
CLINCHING/GRINDING TEETH
MOUTH BREATHING
EXTRACTION OF TEETH
THUMB/FINGER SUCKING (past or present)
JAW PAIN/ JAW JOINT LOCKED
TONGUE THRUST
LIP BITING/SUCKING
ROOT CANAL TREATMENT
9 S 9th Street, Nashville, TN 37206 | 615-420-2742 (P) | elevationorthodontics.com
PLEASE CIRCLE YES OR NO (if yes, please fill in details)
YES
NO
HAVE YOU HAD A DENTAL CHECK-UP IN LAST 6 MONTHS?
YES
NO
ARE YOU PRESENTLY IN ANY DENTAL PAIN?
YES
NO
HAVE YOU PREVIOUSLY HAD AN ORTHO CONSULT?
HOW FREQUENT ARE YOUR DENTAL CHECK-UPS?
TWICE PER YEAR
ONCE PER YEAR
ONLY EMERGENCIES
NONE
HOW OFTEN DO YOU BRUSH?
1X DAILY
2X DAILY
3X DAILY
4X DAILY
5X DAILY
MORNING & BEDTIME
FOLLOWING MEALS
RARELY BRUSH
NEVER
HOW OFTEN DO YOU FLOSS?
1X DAILY
2X DAILY
3X DAILY
MORE THAN 3X DAILY
FOLLOWING MEALS
OCCASIONALLY
RARELY
NEVER
NAME OF GENERAL DENTIST:
NAME OF ORAL SURGEON (if applicable):
NAME OF PERIODONTIST (if applicable):
PLEASE CIRCLE YES OR NO (if yes, please fill in details)
YES
NO
HAVE YOU EVER LOST AND/OR CHIPPED ANY TEETH?
YES
NO
GUMS BLEED WHEN BRUSHING?
YES
NO
HAVE YOUR TONSILS OR ADENOIDS BEEN REMOVED?
YES
NO
ANY OTHER MEMBER OF PATIENT’S FAMILY HAD ORTHO TREATMENT?
YES
NO
WAS PATIENT AWARE AN ORTHODONTIC PROBLEM MAY EXIST BEFORE BEING REFERRED TO ELEVATION ORTHODONTICS?
FEMALE PATIENTS ONLY:
YES
NO
ARE YOU PREGNANT AT THIS TIME?
WHAT DO YOU WANT TO DISCUSS TODAY AT ELEVATION ORTHODONTICS?
I CERTIFY TO THE BEST OF MY KNOWLEDGE THAT ALL ANSWERS HAVE BEEN ANSWERED TRUTHFULLY AND AGREE TO INFORM THIS OFFICE OF ANY CHANGES IN MY DENTAL/ MEDICAL HISTORY.
PATIENT SIGNATURE
Date:
9 S 9th Street, Nashville, TN 37206 | 615-420-2742 (P) | elevationorthodontics.com
PATIENT DISCLOSURES
I HEREBY GIVE PERMISSION TO ELEVATION ORTHODONTICS AND THE CLINICAL STAFF TO TAKE ANY RADIOGRAPHS, PHOTOGRAPHS, AND/OR STUDY MODELS DEEMED NECESSARY TO ALLOW COMPLETE DIAGNOSIS AND TREATMENT PLANNING.
COLLECTION POLICY
IN ALL CASES, THE PATIENT IS RESPONSIBLE FOR PAYMENT OF THEIR ACCOUNT. ELEVATION ORTHODONTICS WILL FILE A CLAIM TO THE PATIENT’S INSURANCE COMPANY WHEN NECESSARY. PATIENT HEREBY AUTHORIZES AND ASSIGNS APPLICABLE INSURANCE BENEFITS TO BE PAID DIRECTLY TO THE ORTHODONTIST. PATIENT IS FINANCIALLY RESPONSIBLE FOR NON-COVERED SERVICES. PATIENT AUTHORIZES RELEASE OF INFORMATION NECESSARY TO PROCESS INSURANCE CLAIMS.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Reproduction of this material by dentists and their staff is permitted. Any other use, duplication or distribution by any other party requires the prior written approval of the American Dental Association. This material is educational only, does not constitute legal advice, and covers only federal, not state law. Changes in applicable laws or regulations may require revision. Dentists should contact their personal attorneys for legal advice pertaining to HIPAA compliance, the HITECH Act, and the U.S. Department of Health and Human Services rules and regulations.
PATIENT SIGNATURE
Date:
9 S 9th Street, Nashville, TN 37206 | 615-420-2742 (P) | elevationorthodontics.com
SOCIAL MEDIA / PHOTO CONSENT FORM
ELEVATION ORTHODONTICS (EO) WOULD LIKE YOUR PERMISSION TO USE IMAGES TAKEN IN OFFICE TO SHOWCASE EXTRAORDINARY BEFORE AND AFTER SMILES ON OUR WEBSITE, FACEBOOK, INSTAGRAM, AND OTHER IN-OFFICE MATERIALS.
PLEASE INDICATE BELOW THE FOLLOWING AREAS WHERE YOU CONSENT TO THE USE OF YOUR PICTURES:
EO WEBSITE
EO FACEBOOK/INSTAGRAM
EO IN-OFFICE MATERIALS (NEWSLETTER, ETC.)
I GRANT PERMISSION FOR PHOTOGRAPHS OF ME TO BE USED IN THE FORMATS INDICATED ABOVE.
I GRANT PERMISSION FOR PHOTOGRAPHS OF ME TO BE USED FOR IN-OFFICE EDUCATION USE ONLY.
I DO NOT GRANT PERMISSION FOR PHOTOGRAPHS OF ME TO BE USED IN ANY OF THE FORMATS INDICATED ABOVE.
PATIENT/PARENT OR GUARDIAN SIGNATURE
Date: