Retention
Medical History

Patient Information:

Today’s Date: *

Name:* LAST

FIRST

Birthdate:*

Cell phone #:*

Email address:

Home Address:*

CITY

STATE

ZIP

If patient is a minor, who is accompanying your child?:

Name:

Relation:

Who is your dentist and when was last visit?*

In the event of an emergency, who should we contact?

Name:*

Cell Phone:*

Medical History

Do you need to take antibiotics before getting your teeth cleaned at the dentist?*

Yes

Are you or have you ever taken any medications for osteoporosis?

Yes

Please list any serious medical conditions that you have or ever had:

Please list any prescriptions/over-the-counter drugs that you are currently taking:

Please list all drugs/things that you are allergic to:*

Do you now or have you ever experienced any pain/tenderness in your jaw joint (TMJ/TMD)?*

Yes

What are you here for today?*

Dental Insurance

Name of Insurance Company:

Name of Insured:

Date of Birth of Insured:

Policy ID Number:

I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in medical status. I authorize the dental staff to perform the necessary dental services that may be needed

Signature of patient, parent or guardian*

Date*

OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY

I verbally reviewed the medical / dental information above with the parent / guardian and patient named herein.

Doctors Comments:

Initials:

Today’s Date:

Privacy Consent and Email Authorization

This form is optional under the U.S. Department of Health and Human Services patient privacy regulations.

Your protected health information such as name, address, dates, phone/fax numbers, email and social security numbers may be used in connection with your treatment, payments on your account, or health care operations. You may revoke your consent, in writing, at any time.

All insurance electronic claims are done with encryption through a secure website.

At times we may need to communicate with you, your dentist and other health care providers via email. By signing this form you give Cohen Orthodontics permission to communicate with you and your health care providers and insurance providers via email or other electronic means, without encryption or special security precautions, which may be accessed by a third party while in transit. The patient information that may be emailed may include x-rays, photos, health history, diagnosis, treatment, and payment records. Cohen Orthodontics DOES NOT email sensitive personal information such as social security numbers, credit card numbers, mental health diagnosis, genetic information etc.

You can tell us in writing to stop emailing your patient information at any time. This will not affect emails that Cohen Orthodontics already sent before receiving your written instructions to stop.

Patient name (please print):

Do you agree?*

Yes