Adult Health History Form

For patients over 18 years old

PATIENT INFORMATION

Legal Name:

First Name

Middle Initial

Last Name

Preferred Name

Date of Birth

Social Security #

Birth Sex

MaleFemaleDecline to Answer

Gender Identity

Male

Female

Transgender Man/transman

Transgender Woman/transwoman

Genderqueer/gender nonconforming neither exclusively male nor female

Additional gender category, please specify:

Decline to Answer

Preferred Pronouns

He/Him

She/Her

They/Them

Other, please specify:

Race/Ethnicity

Name/age and relationship of others living in the household

Home Address

City

State

Zip

Who is the primary contact for this patient?

SelfOther(please list below)

Primary Contact Name

Relationship to Patient

Primary Phone Number

Secondary Phone Number

Email Address

Employer

Occupation

MEDICAL INFORMATION

Primary Physician

Address/Phone

Medical Specialists

Address/Phone

Are you being treated by a physician at this time?

YesNo

Reason

Are you taking any medication (prescription or over the counter), vitamins, or dietary supplements?

YesNo

List Name(s)

Dose, frequency, & date started

Have you ever been hospitalized, had surgery, or a significant injury, or been treated in an emergency department?

YesNo

List date & describe

Women:Are you pregnant or currently breastfeeding?

YesNo

SECONDARY CONTACT INFORMATION (IF APPLICABLE)

Name

Relationship to Patient

Email Address

Home Phone

Cell Phone

Work Phone

Is address the same as patient’s address? If no, please list below

YesNo

Address

City

State

Zip

Date of Birth

Employer and Occupation

EMERGENCY CONTACT INFORMATION

First and Last Name

Relationship to Patient

Phone Number

RELEASE OF INFORMATION

Please list individuals that are OK to have appointment or medically related information released to concerning the patient. List up to 4 people.

First and Last Name

Relationship to Patient

First and Last Name

Relationship to Patient

First and Last Name

Relationship to Patient

First and Last Name

Relationship to Patient

FINANCIAL RESPONSIBILITY

Who is financially responsible for this account?

Address (if different from page 1)

City

State

Zip

Phone Number

E-mail

Social Security Number

Employer

Who will be responsible for bringing patient to appointments?

DENTAL INSURANCE

Primary policy holder's full name

Policy Holder Birthdate

Social Security #

Relationship to patient

Address and phone (if not previously listed)

Employer

Address (street, city, zip)

Insurance Company

Group #

Policy #

Insurance Company Phone # (on back of card)

Does this policy have orthodontic benefits?YesNoDon't know

Secondary policy holder's full name

Policy Holder Birthdate

Social Security #

Relationship to patient

Address and phone (if not previously listed)

Employer

Address (street, city, zip)

Insurance Company

Group #

Policy #

Insurance Company Phone # (on back of card)

Does this policy have orthodontic benefits?YesNoDon't know

MEDICAL INSURANCE

Policy holder's full name

Insurance Company

RELEASE AND WAIVER

I have read the above questions and understand them. I will not hold Surfside Smile Co. Pediatric Dentistry & Orthodontics, my dentist and/or orthodontist, or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my provider of any changes in my child's medical or dental health.

I authorize release of any information regarding my child's dental or orthodontic treatment to my dental and/or medical insurance company necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office and I understand that I am responsible for any amount not covered by insurance.

Signature of Patient or Responsible Party

Printed Name

Relationship to Patient (If Not Self)

Date

PRIVACY CONSENT

This form is optional under the new patient privacy regulations recently issued by the United States Department of Health and Human Services. We have elected to use this form. Prior to commencing your orthodontic treatment, you should review, sign and date this form.

Your protected health information (i.e., individually identifiable information such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used in connection with your treatment, payment of your account or health care operations (i.e., performance reviews, certification, accreditation and licensure).

You have the right to review our office's privacy notice prior to signing this Consent, a copy of which was given to you with this Consent. You have the right to request restrictions on the use of your protected health information. However, we are not required to, and may not, honor your request.

We may amend the attached privacy notice at any time. If we do, we will provide you with a copy of the changes, and the changes may not be implemented prior to the effective date of the revised notice.

You may revoke this Consent at any time in writing. However, such a revocation will not be effective to the extent that any action has been taken in reliance on this Consent.

Thank you for your cooperation. Please let us know if you have any questions.

Signature of Patient or Responsible Party

Printed Name

Relationship to Patient (If Not Self)

Date

Not offering consent

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to signCommunications barriers prohibited obtaining the acknowledgementAn emergency situation prevented us from obtaining acknowledgementOther (Please Specify)

Adult Health History Form

For patients over 18 years old

PATIENT INFORMATION

MEDICAL INFORMATION

Please mark YES if you have a history of the following conditions. For each "YES", provide details in the box at the bottom of this list. Mark NO after each line if none of those conditions applies to you.

SECONDARY CONTACT INFORMATION (IF APPLICABLE)

EMERGENCY CONTACT INFORMATION

RELEASE OF INFORMATION

DENTAL HEALTH QUESTIONNAIRE

Please complete the following orthodontic supplemental section if you are registering as an ORTHODONTIC patient

ORTHODONTIC SUPPLEMENTAL FORM

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL INSURANCE

RELEASE AND WAIVER

PRIVACY CONSENT