Dr. David Lenhart

Dr. Sydney Sherman

lenhartorthodontics.com

New Patient Form

Patient Full Name:*

Preferred Name:

MaleFemale

Date of Birth:

Home Address:

City:

State:

Zip:

Preferred Email:

Preferred Phone#:

CellHomeWork

If patient is under 18:

School:

Grade:

Favorite Sports:

Favorite Hobbies:

Siblings (Name/Age):

1)

2)

3)

Pets:

Favorite Movie:

Have any family members previously been treated at our office:*

NoYes

Parent's Information:

Patient Lives with:

Both ParentsDadMomOther

Parent/Guardian's Full Name:

Date of Birth:

Address (if different than patient):

Preferred Email:

Preferred Phone#:

CellHomeWork

Parent/Guardian's Full Name:

Date of Birth:

Address (if different than patient):

Preferred Email:

Preferred Phone#:

CellHomeWork

Occupation:

Employer:

Are you aware that some appointments will have to be during school hours?

YesNo

How did you hear about our office? Check all that apply. Please be specific for future marketing efforts:

Dentist Friend Web Search Social MediaImmediate family member(s) in treatmentSponsorship/Community EventOther

Current Dentist:*

Date of Last Cleaning (approximate)

List any other dental specialists currently treating the patient:

Chief Concern:

Who is concerned?*

Dentist Patient Parents (if under 18)

How does the patient feel about orthodontic treatment?

Any previous orthodontic treatment or consultations?

Dental Insurance: (Fill out all fields — if you provide a copy of your insurance card, still fill out DOB and SSN. If you have Delta Dental please specify what state.)

Primary Policyholder Full Name:

Date of Birth:

Employer:

Policyholder SSN:

Relationship to Patient:

Insurance Company:

Group#:

ID#:

Secondary Policyholder Full Name:

Date of Birth:

Employer:

Policyholder SSN:

Relationship to Patient:

Insurance Company:

Group#:

ID#:

Medical History

Are you in overall good health?*

YesNo

Have you had a physical in the last year?*

YesNo

Are you currently under the care of a physician or specialist?*

YesNo

If yes, explain

Has the patient's physician recommended pre-medication with antibiotics prior to dental appointments?*

YesNo

Do you have allergies to any of the following? (please list additional severe allergies under "other")

LatexMetals or AcrylicsAntibiotics or drugsOther

Is there a family history of any of the following conditions?

Severe arthritisSevere allergiesExtra or missing teethJaw size imbalance or jaw surgery

If so, please explain:

Do you chew or smoke tobacco?*

YesNo

Do you have a history of any of the following conditions: (Check any appropriate boxes and explain below):

ADD/ ADHD

Anemia/bleeding disorder

Arthritis

Asthma

Autism

Birth Defects

Cancer/Tumors

Diabetes

Endocrine/Thyroid Disease

Epilepsy

Fainting

Frequent Headaches/Migraines

Heart Disease

High Blood Pressure

Kidney disease

Liver Disease

Nervous Disorders

Prolonged Bleeding

Respiratory Disease

Additional Information:

Please list all medications currently being taken, including prescription, over-the-counter, supplements, and herbal medications.

Medication:

Taken for:

Medication:

Taken for:

Any history of bisphosphonate use? (Zometa, Aredla, Didronel, Fosamax, Actonel, Boniva, Skelid, Didronel)*

YesNo

Female Patients Only:

Has menstruation started? If yes, date?

YesNo

Is the patient pregnant?

YesNo

Dental History

How often do you brush?

Floss?

Are you currently experiencing any of the following?

Sensitive teeth/gumsDifficulty chewingSoreness in jaw musclesBroken/chipped teethClicking/locking of jaw jointFrequent canker soresFood frequently trapped between teethSpeech problemsSleep ApneaMouth breathing habit

Have you previously experienced any of the following (if so, please explain below)?

Dental traumaJaw fractures or cystsGum problems (periodontal disease)

Any current habits?

Thumb suckingFingernail bitingGrinding/Clenching

If yes to any of the above, please explain:

Benefits

Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and general dental health. Teeth, gums, and jaws are intricate body parts and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth can change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understood this paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental health. In addition, I authorize Dr. Lenhart and/or Dr. Sherman to perform a complete orthodontic evaluation.

Signature:*

Date:*

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

SECTION A: PATIENT INFORMATION

Name:

Address:

Telephone:

SECTION B: TO THE PATIENT—PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activities, healthcare operations, of the uses and disclosures we may make of your protected information and of other important matters about your protected health information. You may request to see a copy of our Notice of Privacy Practices.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our notice, at any time by contacting:

Contact Person:

David M. Lenhart DDS MSD

Telephone:

(419) 882-6970

Fax:

(419) 882-1928

E-mail:

N/A

Address:

4323 N Holland Sylvania Rd Toledo, OH 43623

Right to Revoke: You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the contact person listed above. Please understand that revocation of this consent will not affect any action we took in reliance to this consent before we received your revocation and that we may decline to treat you or to continue treating you if you revoke this consent.

SIGNATURE

I, have had the full opportunity to read and consider the contents of this consent form and your Notice of Privacy Practices. I understand that by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.

Signature:*

(Parent signature if patient is a minor)

Date:*

Relationship to Patient:

Reproduction and use of this form by dentists and their staff Is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.