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

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Rarely
1-2 times/day
3 or more times/day
Rarely
1-2 times/day
3 or more times/day
Rarely
1-2 times/day
3 or more times/day
Rarely
1-2 times/day
3 or more times/day

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

ORTHODONTIC SUPPLEMENTAL FORM

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL INSURANCE

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.

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.