Sellers Orthodontics Child New Patient Form

KEITH T. SELLERS, D.D.S., M.S.

Orthodontic Acquaintance Form

Acct, #:

Date

Child Patient Information

Patient Name:

Preferred Name:

Address: Street

City

State

Zip

Phone:

Cell Home

Work Phone:

Male Female

Age:

Birthdate:

Email:

General Dentist:

Date of Last Cleaning:

Outstanding Dental Treatment to be Completed:

Special Interests/Hobbies:

School

Responsible Party Information

Father

SS#

Address

City

State

Zip

Occupation

Cell#

Employer

Date of Birth

Mother

SS#

Address

City

State

Zip

Occupation

Cell#

Employer

Date of Birth

Name and ages of siblings

Parent's Martial Status:

Single Married Partnered Separated Divorced Widowed

Have we previously treated any family members?

Yes No

If so, Whom:

Are you nervous or anxious about dental treatment?

Yes No

If so, What concerns do you have?

How did you hear about us?

General Dentist:

Friend/Family:

Internet Search

Location

Staff Member:

Social Media:

Invisalign Website

Other

I authorize the release of any prior dental/medical records and give permission to use records in scientific presentations.

Yes No

I authorize the use of photos on social media.

Yes No

I have received or read a copy of this office's Notice of Privacy Practices.

Yes No

Responsible Party Signature

Patient Name:

Patient#:

MEDICAL HISTORY

Physician's Name

Please list any medical conditions we need to know about:

Have tonsils and adenoids been removed?

Yes No

What age?

Is patient pregnant?

Yes No

List any medications:

List any allergies:

Has patient ever taken bisphosphonates for osteoporosis (Ex. Fosamax, Boniva)?

Yes No

If so, dates taken:

Does the patient have any of the following?

ADD/ ADHD

Autism

Sleep Apnea

CPAP

DENTAL HISTORY

Have there ever been any injuries to the face, mouth, or teeth?

Yes No

Does patient have any speech problems?

Yes No

Has patient ever been informed of any missing or extra permanent teeth?

Yes No

Has patient ever consulted or been treated by an orthodontist previously?

Yes No

Did either parent have orthodontic treatment?

Yes No

Does patient currently wear a nightguard?

Yes No

Patient's attitude toward orthodontic treatment:

wants treatment

treatment if necessary

unwilling but agrees

uncooperative

Does the patient have any of the following oral habits:

Thumb / finger sucking

Tongue thrust

Mouth breathing

Tongue sucking

Clenching / grinding

Sellers Orthodontics

Authorization for Release of Information - Compound Release

Name of Patient

Date of Birth

Sellers Orthodontics is authorized to release protected health information about the above named patient in the following manner and to identified persons.

Entity to Receive Information.

Check each person/entity that you approve to receive information.

Description of information to be released.

Check each that can be given to person/entity on the left in the same section.

Voice Mail

Appointment Reminders

Other person (s) (provide name and phone number) (i.e. parent, Grandparent, Aunt, Uncle, Spouse, Nanny etc)

Treatment/ Treatment Plans

Financials

Email communication-Provide email address*

*For email communication to occur, please accept the disclosure below:

Financial

Treatment/ Treatment Plans

Appointment reminders

Breach notification

Text communication - Provide number *

*For text communication to occur, accept the disclosure below:

Appointment reminder

Other

For email and/or text communication I understand that if information is not sent in an encrypted manner there is a risk it could be accessed inannrooriatelv. I still elect to receive email and/or text communication as selected.

Photo of patient received by patient or legal guardian

Photo taken by staff (Example: pre/post procedure)

Other

May be posted in office

May be posted on Website

Other

Patient Rights:

I have the right to revoke this authorization at any time.
I may inspect or copy the protected health information to be disclosed as described in this document.
Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.
I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.

This authorization will remain in effect until revoked by the patient.

Signature of Patient or Personal Representative

Date

*Description of Personal Representative's Authority (attach necessary documentation)

ORTHODONTIC INSURANCE INFORMATION

DENTAL INSURANCE INFORMATION ONLY PLEASE

We will be happy to assist you in determining your orthodontic insurance benefits, however all information must be completed and signed.

Name of Patient

Date of birth

Name of Insured party

Date of birth

Home address

City/State/Zip

SS#/Member or Subscriber ID of insured

Home Phone

Employer

Work Phone

Work Address

Dental Insurance Company

Group#

Insurance Address

Phone

City/State/Zip

I hereby authorize release of any information relating to this claim

Signature of insured party

I hereby authorize payment directly to Dr. Sellers

Signature of insured party

I do not have Dental Coverage