PATIENT INFORMATION (CONFIDENTIAL)

Date:

Name:

First

M.

Last

Preferred Name to Be Called:

Date of Birth:

Age:

Sex Listed on Birth Certificate:

MaleFemaleDecline to Answer

Gender You Identify as:

Male

Female

Transgender MtF Female

Transgender FtM Male

Other, Please Specify:

Decline to Answer

Preferred Pronouns:

He/HimShe/HerThey/Them

Mailing Address:

Street

City

State

Zip Code

Home Phone:

Cell Phone:

Carrier:

Work Phone:

Email Address

(For students) School:

Grade:

(For children) Sports and/or Hobbies:

Whom may we thank for referring you to us?

What concerns do you have regarding you or your child's teeth that you would like Dr. Rocha to evaluate?

Type “X” next to any of the following that you may have reservations about regarding orthodontic treatment:

AppearanceCostPainTime

(For children) Names and ages of brothers and sisters:

Have any members of your family been patients in our office?

YesNo

Name(s):

Primary Responsible Party:

Name:

Relation to patient:

Date of Birth:

Home Phone:

Work Phone:

Cell Phone:

Cell Carrier:

Home Address:

Email Address:

Secondary Responsible Party:

Name:

Relation to patient:

Date of Birth:

Home Phone:

Work Phone:

Cell Phone:

Cell Carrier:

Home Address:

Email Address:

Occupation:

Employer:

Person financially responsible for this account:

Emergency Contact Person (Name/Relationship/Phone):

MEDICAL INFORMATION

Physician:

Date of Last Visit:

Address:

Office Phone:

Now or in the past, has the patient had?

Allergies or reactions to any of the following:

Medications:

YesNo

Is the patient taking medication, nutrient supplements, herbal medications or nonprescription medicine? Please name them and what they are taken for:

Does your physician require you to take any premedication before dental appointments?

YesNo

Please describe:

Are there any major illnesses or medical conditions not mentioned above that we should be aware of?

Women and Girls:

YesNo

Has the patient started her monthly periods? Approximately when?

YesNo

Is the patient pregnant?

DENTAL INFORMATION

Dentist:

Office Phone:

Address:

Date of last visit:

Frequency of visits:

How many times a day does the patient brush their teeth?

Floss their teeth?

Now or in the past, has the patient had?

YesNo

Prior orthodontic examination or treatment? When?

YesNo

Started teething very early or late?

YesNo

Teeth sensitive to hot or cold?

YesNo

History of speech problems? Been under the care of a speech therapist?

YesNo

Mouth breathing habit?

YesNo

Snoring or difficulty breathing?

YesNo

Abnormal swallowing habit (tongue thrusting)

YesNo

Thumb, finger or lip sucking habit? Until what age?

YesNo

Nail biting habit?

YesNo

Frequent canker sores or cold sores?

YesNo

Gums bleed when brushed or flossed?

YesNo

Wisdom teeth extracted?

YesNo

Extra or missing teeth from birth?

YesNo

Periodontal “gum problems”?

YesNo

Been under the care of a dental specialist? (Past or present)

Specialist:

YesNo

Taking any forms of fluoride?

YesNo

Any serious trouble associated with previous dental treatment?

YesNo

Any relative with similar tooth or jaw relationships?

YesNo

Sensitive or self-conscious about teeth?

Are there any dental conditions not mentioned above that you feel we should be aware of?

ORTHODONTIC INSURANCE INFORMATION

YesNo

Does the patient have Orthodontic Coverage?

YesNo

Does the patient have Dental Coverage?

Primary Orthodontic Coverage

Insurance Company's Name:

Insurance Company's Address:

Insurance Company's Phone #:

Group # (Plan, Local or Policy #):

Insured's Name:

Insured's Birth date:

Relation to Patient

Insured's SS#:

Patient's SS#:

Insured's Employer:

Employer's Address:

Secondary Orthodontic Coverage

Insurance Company's Name:

Insurance Company's Address:

Insurance Company's Phone #:

Group # (Plan, Local or Policy #):

Insured's Name:

Insured's Birth date:

Relation to Patient:

Insured's SS#:

Patient's SS#

Insured’s Employer:

Employer's Address

SIGNATURE(S) and DATE(S)

I/We certify that the information on this form is true and correct to the best of my/our knowledge, that it will be held in the strictest of confidence, and I/we will notify you of any changes

Name:

Signature:

date:

Name:

Signature:

date:

TEMPOROMANDIBULAR JOINT (TMJ) SCREENING FORM

Patient Name:

Date of Birth:

Age:

Please indicate “YES” or “NO” below whether or not the patient now experiences or has experienced the following:

YesNo

Generalized jaw pain

YesNo

Painful opening or closing of jaw

YesNo

Joint noises upon opening or closing

YesNo

Joint popping upon opening or closing

YesNo

Difficulty or limitation in opening or movement of jaw

YesNo

Irregular jaw movement when opening or closing jaw

YesNo

Jaw “sticking”, “locking”, or dislocation

YesNo

Stiff, tight or tired jaws

YesNo

Facial pain (around ears, temples, and/or cheeks)

YesNo

Facial or jaw pain or soreness when chewing

YesNo

Recent or past injury of head, neck or jaw(s)

YesNo

Headaches

YesNo

Ear pain, ringing of the ear, or stuffiness

YesNo

Difficulty swallowing

YesNo

Neck aches

YesNo

Tooth pain of unknown origin

YesNo

Recent or evolving changes in bite

YesNo

Continued tooth or jaw pain following dental treatment

YesNo

Tooth clenching or grinding

YesNo

Wear, have worn, or have been recommended a night guard for clenching or grinding

YesNo

Current or past history of arthritic joints

YesNo

Past history of treatment for TMJ issues

Responsible Party Printed Name

Responsible Party Signature

Date

CONSENT TO REQUEST/RELEASE DENTAL/ORTHODONTIC RECORDS AND INSURANCE INFORMATION

I do hereby consent and authorize:

(Dentist/Orthodontist Name/Office)
to release to Valley Orthodontics information in my/my child's record including current and previous dental/orthodontic records from other practitioners which are part of my/my child's record.
Valley Orthodontics to request information from my insurance company and other providers.
Valley Orthodontics to release dental/orthodontic records in the event that information is needed by other dental specialists or my insurance company.

I understand Valley Orthodontics prefers digital records are sent in a digital format via email whenever possible and that these records may be sent and received from unsecured email sources. I may revoke this authorization at any time

Patient Name: (printed):

Patient’s Date of Birth: :

(signed)

Guardian Name: (printed)

(signed)

Guardian relationship to patient:

Date:

Please send records to:

Valley Orthodontics

2400 Las Gallinas Avenue, Suite 130

San Rafael, CA 94903

Phone: 415-479-2400

FAX: 415-901-2628

Email: smiles@valleyorthodontics.net

PRIVACY NOTICE

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

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 or disclosed by us in one or more of the following respects:

To other health care providers (i.e. your general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you (i.e. to determine the results of cleanings, surgery, etc.);
To third party payers or spouses (i.e. insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e. to determine benefits, dates of payment, etc.);
To certifying, licensing and accrediting bodies (i.e. the American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation;
Internally, to all staff members who have any role in your treatment;
To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling, etc.;
To your family and close friends involved in your treatment; and/or,
We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke.

Under the new privacy rules, you have the right to:

Request restrictions on the use and disclosure of your protected health information;
Request confidential communication of your protected health information;
Inspect and obtain copies of your protected health information through asking us;
Amend or modify your protected health information in certain circumstances;
Receive an accounting of certain disclosures made by us of your protected health information; and,
You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our Privacy Contact Person at our office address) or the United States Secretary of Health and Human Services (which must be filed within 180 days of the violation.)

We have the following duties under the privacy rules:

By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information;
To abide by the terms of our Privacy Notice that is currently in effect; and,
To advise you of our right to change the terms of this Privacy Notice and to make the new notice provisions effective for all protected health information maintained by us, and that if we do so, we will provide you with a copy of the revised Privacy Notice.

Please note that we are not obligated to:

Honor any request by you to restrict the use or disclosure of your protected health information;
Amend your protected health information if, for example, it is accurate and complete; or,
Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.

This Privacy Notice is effective as of the date of your signature. If you have any questions about the information in this notice, please ask for our Privacy Contact Person or direct your questions to this person at our office address Thank you.

PATIENT ACKNOWLEDGEMENT

I hereby acknowledge that I have received and reviewed a copy of this Privacy Notice.

Patient Name

Patient or Responsible Party Signature

Date