Peter M. Greco, D.M.D.Alexandra K. Greco, D.D.S.

Date:

Name:

Title:

Nickname:

Preferred Pronouns:

Address:

Email:

Phone (Cell):

Parents (If Patient Is A Minor):

Other Family Members Seen By Us:

Family Dentist:

Referred By:

Dental Insurance:

If Patient Is Under 18, Please Complete This Section.

Relationship to Patient:

Do you have legal custody of this child?:

Yes

No

What concerns you most about your teeth?:

Do you have any allergy to

Tetracycline

Yes

No

Any Metal/Plastics

Yes

No

Latex

Yes

No

Dental Anesthetics

Yes

No

Have you ever had or been evaluated for orthodontic treatment?

Yes

No

Have you ever had a serious/difficult problem associated with any previous dental work?

Yes

No

Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ)?

Yes

No

Your current dental health is:

Good

Fair

Poor

Do you like your smile?

Yes

No

Do your gums ever bleed?

Yes

No

Have you ever had an injury to your mouth, teeth, or chin?

Yes

No

Do you have any speech problems?:

Do you generally breathe through your mouth?

When awake?

Yes

No

When asleep?

Yes

No

Health Questionnaire

If the form is being completed by a parent or guardian, all questions pertain to the patient, not the parent or guardian.

Date:

Name:

Title:

Parent or Guardian’s Name (if patient is a minor):

Address:

City:

State:

Zip:

Social Security #:

Date of Birth:

Home Phone:

Cell Phone:

Patient’s Marital Status:

Single

Married

Divorced

Widowed

Number of Children:

Section A

Occupation/School:

Grade (if in school):

Medical Doctor’s Name and Address:

Date of Last Medical Visit:

Dentist’s Name and Address:

Dentist’s Phone #:

Date of Last Dental Visit:

Date of Last Dental X-rays:

Major Reason for Seeking Orthodontic Treatment:

Section I Family History

Yes

No

If patient is a child, is he/she adopted?

Yes

No

Does anyone in your family have a facial condition similar to yours?

If yes, please describe:

Yes

No

Do you have a family history of permanent teeth failing to form or erupt?

Yes

No

Do you have a family history of periodontal (gum) disease?

Section J Dental Insurance Information

Insured’s name:

Insurance company:

Insured’s employer:

Insured’s Social Security #:

Group#:

ID#:

Insured’s Date of Birth:

If you have Dual Dental Insurance Coverage:

Insured’s name:

Insurance company:

Insured’s employer:

Insured’s Social Security #:

Group#:

ID#:

Insured’s Date of Birth:

Health questionnaire completed by:(Parent or guardian if patient is a minor)

Signature

Date completed:

Consent to Use and Disclose Protected Health Information

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

Your protected health information will be used by Greco Orthodontics or disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of the practice.

THE NOTICE OF PRIVACY PRACTICES

Greco Orthodontics is required to provide to you a notice that describes how information about you may be used and disclosed. Additionally, we must provide you information on how you may get access to this information. These policies and practices are defined in the "Notice of Privacy Policies and Practices" brochure. A copy of the brochure is available for your review upon request.

YOU MAY PLACE RESTRICTIONS ON THE USE OR DISCLOSURE OF YOUR HEALTH INFORMATION

You may request a restriction on the use or disclosure of your protected health information. However, Greco Orthodontics may or may not agree to your request to restrict the use or disclosure of your protected health information. You may be asked to complete an authorization to activate this request. Please consult with a practice representative or Dr. Greco if you would like additional information or clarification.

It is a violation of the federal privacy standards if Greco Orthodontics agrees and fails to comply with your request. The restrictions requested will not affect use and disclosure of your information before the date of your request. If you still have questions after reviewing the Notice of Privacy Brochure, please consult with a practice representative or Dr. Greco at the location and contact information listed on the back of the brochure.

YOU MAY REVOKE THIS CONSENT AT ANYTIME

You may revoke this consent at anytime; however, Greco Orthodontics requires that you must revoke this consent in writing. If you choose to revoke this consent, the revocation will not affect use and disclosure of your information before the date of your request.

CHANGES TO PRIVACY PRACTICES

Greco Orthodontics reserves the right to change or modify the privacy practices outlined in the Notice of Privacy Brochure. Dr. Greco will notify you of any changes of privacy practices either by mail, at your next appointment, or any other pre-approved method that you request.

SIGNATURE

I have reviewed this consent form, received the brochure entitled "Notice of Privacy Polices and Practices" and give my permission to Greco Orthodontics to use and disclose my health information in accordance with this consent and the notice provided.

Name of Patient (Print or Type)

Signature of Patient

Date

Patient Representative (Print or Type)

Signature of Representative

Date

Relationship of Patient Representative to Patient

Health Questionnaire

Section A

Section B

Section C Medical History

Section D Allergy History

Section E Medication Use

Section F Women Only—otherwise proceed to Section G

Section G Oral Health

Section H Social History