Patient Information - Adult Form

Patient's Name*

Nickname (if preferred)*

Age*

Birth Date*

SSN

SexMaleFemale

Email*

Home Phone

Cell Phone

Home Address

City

State / Province

Postal / Zip Code

General Dentist*

How did you hear about our office/whom may we thank for recommending our office?*

Have we treated another member of your family? If YES, Name(s)

Have you visited an orthodontist before? If YES, for what reason?

Primary Insurance Information

Insured's Employer

Occupation

Insurance Company Name

Insurance Company Phone

Insurance Company Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Address of Subscriber (If different than above)

Street Address Line 2

City

State / Province

Postal / Zip Code

Insured's Name*

SSN (If different from above)

Insured's DOB*

Relationship

Group or Plan #

Secondary Insurance Information

Insured's Employer

Occupation

Insurance Company Name

Insurance Company Phone

Insured's Insurance Company Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Address of Subscriber (If different than above)

Street Address Line 2

City

State / Province

Postal / Zip Code

Insured's Name*

SSN (If different from above)

Insured's DOB*

Relationship

Group or Plan #

Dental and Medical History

Are you currently under the care of a physician? If YES, for what reason?

Physician's Physician

Phone

History of major illness?* YesNo

If yes, please describe

Any sensitivities or allergies?* YesNo

If yes, please list

Currently taking any medications?* YesNo

If yes, please list

Has your physician/dentist recommended antibiotics before dental treatment?* YesNo

If yes, medication

Have there been injuries to your face, mouth or chin?* YesNo

If yes, explain

Have you ever had pain/tenderness in your jaw joint (TMJ/TMD)?* YesNo

If yes, explain

Please check atleast one field

Do/Did you have any of the following habits?*

Grinding Teeth

Chronic Mouth Breathing

Tobacco Use

Finger/Thumb Sucking

Speech Problems

Tongue Thrusting

Chewing/Eating Problems

None

Are there other dental issues not listed that you would like to discuss or have treated?* YesNo

If yes, explain

Your "Smile" Questionnaire

What changes would you like to see with your teeth?*

Please check atleast one field

Are you concerned with:*

Teeth that are crooked or crowded?

Spaces between your teeth?

Your front teeth "sticking out too much"?

Too much or too little gum tissue showing when you smile?

An overbite?

Teeth not white enough?

Other

Privacy Notice

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Each time you visit our office, we make a record of your visit in order to manage the care you receive. We understand that the medical information that is recorded about you and your health is personal. The confidentiality and privacy of your health information is also protected under both state and federal law.

This Notice of Privacy Practices describes how this office may use and disclose your information and the rights that you have regarding your health information.

How We Will Use or Disclose Your Health Information

Treatment: We will use your health information for treatment. Your 0rthodontist will document in your record his or her expectations of the member of your healthcare team. Members of your healthcare team will then record the actions they took and their observations, so the physician will know how you are responding to treatment.

Payment: We will use your health information for payment. The information on or accompanying the bill or insurance claim may include information that identifies you, your diagnosis, procedures, and supplies used.

Health Care Operations: We may share your information with other health care providers (i.e., your general dentist. oral surgeon, etc.) in connection with our rendering orthodontic treatment. This information will then be used in a continued effort to improve the quality and effectiveness of the services we provide.

Business Associates:We may enter into contracts with persons or entities known as business associates that provide services to or perform functions on our behalf. We may disclose our health information to our business associates so they can perform the job we have asked them to do. once they have agreed in writing to safeguard your information.

Notification /Communication with Family: We may use or disclose information to assist in notifying a family member, personal representative, or another person responsible for your care, of your location, and general condition. If unable to reach your family member or personal representative, then we may leave a message for them at the phone number that they have provided for us. We may disclose to a family member, other relative, or any other person you identify as responsible for your health information relevant to that person's involvement in your care or payment related to your care.

Appointment Reminders/Health Benefits: We may contact you to provide appointment reminders or information about treatment alternatives or other health benefits that may be of interest to you.

Health Care Information Required by Law: We may use and disclose your health information when required by federal or state law and when required in court or administrative proceedings.

Insurance Payments:I hereby authorize and direct payment of dental insurance benefits otherwise payable to me, directly to Parks, Schmit, and Fuller Orthodontics.

The following uses and disclosures will be made only with your authorization. You may revoke your authorization at any time in writing, except to the extent that we have taken action in reliance on the use or disclosure indicated in the authorization.

Name

Signature Clear

Date*: