New Patient Form | Happier Smiles Orthodontics

Dr. Neelab Anwar

Happier Smiles Orthodontics

838 Nordahl Rd Suite #100

San Marcos, CA 92069

Happier Smiles Orthodontics New Patient Form

Save time at the office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form, click the "Submit Form" button at the bottom, and your information will be sent to our office with secure encryption. We will already have your information when you arrive for your first appointment.

Patient Information

First Name

Last Name

I prefer to be called (Nickname)

Address (Street)

City

State

Postal Code

Cell Phone

Home Phone

Email Address

Birth date

Gender Male Female

Social Security Number (U.S. only)

Other family members seen by us

Responsible Party Information

Full Name

Mailing Address (Street)

City

State

Postal Code

Phone

Email Address

Social Security Number (U.S. only)

Birth date

Relationship to Patient

Employer

Dental Insurance Information

Subscriber/Employee

Subscriber ID/SSN

Insurance Company

Group Number

Employer/Group Name

Insurance Phone Number

Emergency Contact Information

Name

Relationship to Patient

Phone

Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.

Physician

Phone

Date of Last Visit

Are you under medical treatment now?

Yes No

Do you use tobacco?

Yes No

Have you been hospitalized for any surgical operations or serious illness in the past 5 years?

Yes No

Are you taking medication(s) including non-prescription medicine?

Yes No

Comment

Are you aware of being allergic to any medications or substance, including metals or latex?

Yes No

Comment

Females Only: Are you pregnant or think you may be?

Yes No

Have you ever taken bisphosphonates (ex. fosomax) for osteoporosis?

Yes No

Please check all that apply:

Please check atleast one field

Hay Fever/Allergies

Cold Sores

Migraines

Diabetes/Glaucoma

Rheumatic Fever

AIDS or HIV Infection

Cardiac Pacemaker

Asthma (Inhaler)

Fainting/Seizures

Thyroid Problem

High/Low Blood Pressure

Heart Trouble

Epilepsy/Convulsions

Leukemia

Kidney/Liver Disease

Anemia

Cancer

Joint Replacement/Implant

Hepatitis/Jaundice

Stomach Troubles/Ulcers

Sinus Problems

Stroke

Radiation Therapy

Respiratory Problems

Bone Disorder

Osteopemia/Osteoporosis

Removal of Adenoids/Tonsils

None of the above

Dental History

General Dentist

Date of Last Cleaning

Are you anxious or nervous about dental treatment?

Yes No

Do you require premedication for dental treatment?

Yes No

Do you feel pain to any of your teeth?

Yes No

Do you snore or have sleep apnea?

Yes No

Do you have any ongoing problems in your jaw with: chronic clicking, pain, difficulty opening or closing, difficulty in chewing?

Yes No

Comment

Do you clench or grind your teeth?

Yes No

Have you ever had speech therapy?

Yes No

Comment

Is there any outstanding dental treatment to be completed?

Yes No

Comment

Do you have any of the following oral habits: nail biting, thumb sucking, tongue thrust while swallowing, mouth breathing?

Yes No

Comment

Reason for consultation (chief concern)

Has the patient had an orthodontic evaluation or treatment before?

If so, when and by whom?

Electronic Signature

Signature

Date:

By electronically signing and clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. I understand it is my responsibility to inform this office of any changes to the patient's medical status. All information is confidential and is accessed only via a secure, encrypted interface. I give Happier Smiles Orthodontics permission to perform the necessary dental services that the patient may need. I agree to the terms of the Privacy Policy with Happier Smiles Orthodontics. A copy of this policy has been made available to me upon request.

Please check atleast one field

What helped you decide to come to Happier Smiles Orthodontics?

Dentist

Friends

Friend's Name:

Family

Family Name:

Social Media

Our Website

Online Reviews

Other

Other:

What is Most Important

We recognize that each patient family has individual needs and expectations.

Our Goal is to Meet and Exceed Yours!

Please briefly describe what is most important to you/your family in choosing an orthodontic specialist.

HIPAA Consent

This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Consent Person or direct your questions to this person at our office address.

Agree

I hereby acknowledge that I have reviewed a copy of this privacy notice

Agree

Photographic / Media / Social Media Consent

I hereby grant permission to Happier Smiles Orthodontics to post my and/or my child's HSO related photo, video or other item to Happier Smiles Orthodontics social media accounts (i.e. Facebook, lnstagram, etc.).

Agree

Authorization for Release of Orthodontic Records and X-Rays:

I hereby authorize Happier Smiles Orthodontics to release my and/or my child's orthodontic records, including x-rays, to my and/or my child's general dentist and/or other dental specialist/health care provider as applicable.

Agree

Authorization for Cell Phone and Email Use

I give my consent to receive email communications regarding treatment information, insurance, account and billing information, and special promotions from the orthodontic practice. I understand that I can withdraw my consent at any time.

Agree

Choose all that apply:

Please check atleast one field

Phone Calls

Text

Neither

Certification:

I certify that I am the authorized representative for the patient.

My relationship to the patient is:

I certify that I am the patient

I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION. I grant authority to the Doctor and Staff to perform all procedures and treatments in my best interest. I authorize the Orthodontist to share treatment information with collaborating dentists and surgeons when appropriate. I authorize the Orthodontist to submit treatment information pertinent to this patient to the Insurance Company for billing purposes only. I understand that, when appropriate, Credit Bureau reports may be obtained only with the responsible party's permission.

Happier Smiles Orthodontics may use your orthodontic records for educational and promotional purposes. I know this is in the Consent form, but it allows us to use their photos, etc. for teaching purposes even if they do not start treatment.

Signature

Date: