Patient Information
     
Last: First: Middle: Sex: Birth date:
Address: City : State: Zip:
Home Phone: E-Mail #1:
Check Appropriate Box: Minor : Single : Married : Divorced : Widowed : Separated :
Patient’s or Parent’s Employer: Work Phone:
Spouse or Parent´s Name: Contact Phone:
Business Address: City: State: Zip:
Spouse or Parent’s Name: Employer: Phone:
If Patient is a Student, Name of School/College: City: State:
Whom may we thank for referring you?:
Person to contact in case of emergency: Phone:
     
Responsible Party
     
Last: First: Middle: Sex:
Address: City: State: Zip:
Home Phone: E-Mail: Birth date:
Driver's License#: Social Security#: Bank:
Employer: Work Phone:
Currently a Patient in our Office?:
     
INSURANCE Information
 
Last: First: Middle: Sex:
Relation to Patient: Social Security #: Birth date:
Employer: Work Phone: Date Employed:
Employer Address: City: State: Zip:
Insurance Company: Group#: Union or Local#:
Address: City: State: Zip:
How Much is Your Deductible?: How Much Have You Used?: Max. Annual Benefit:
     
ADDITIONAL INSURANCE
 
Last: First: Middle: Sex:
Relation to Patient: Social Security#: Birth date:
Employer: Work Phone: Date Employed:
Employer Address: City: State: Zip:
Insurance Company: Group#: Union or Local#:
Address: City: State: Zip:
How Much is Your Deductible? How Much Have You Used? Max. Annual Benefit:
     
DENTAL HISTORY
     
Reason for today’s visit:
Former Dentist:
Address:
Date of last dental visit: Date of last dental X-rays:
Check (√) if you have had any of the following:    
Bad breath Grinding teeth Sensitivity to heat
Bleeding gums Loose teeth or broken fillings Sensitivity to heat
Clicking or popping jaw Periodontal treatment Sensitivity when biting
Food collection between the teeth Sensitivity to cold Sores or growths in your mouth
     
How often do you floss?: How often do you brush?:
     
medical history
     
Physician's Name: Date of last visit:
Have you had any serious illnesses or operations?: If yes, describe:
Have you ever had a blood transfusion?: If yes, give approximate dates:
Do you have or have you had any damaged heart valves or artificial heart valves, including heart murmur?
Women-Are you pregnant? Nursing? Taking birth control pills

Check (√) if you have had any of the following:
Cortisone Treatments Hepatitis Rheumatic Fever
Anemia Cough, Persistent High Blood Pressure Scarlet Fever
Arthritis, Rheumatism Cough up Blood HIV Positive Shortness of Breath
Artificial Heart Valves Diabetes Jaw Pain Skin Rash
Artificial Joints Epilepsy Kidney Disease Stoke
Asthma Fainting Liver Disease Swelling of Feet or Ankless
Back Problems Glaucoma Mitral Valve Prolapse Thyroid Problems
Blood Disease Headaches Nervous Problems Tobacco Habit
Cancer Heart murmur Pacemaker Tonsillitis
Chemical Dependency Heat Problems Psychiatric Care Tuberculosis
Chemotherapy Describe Radiation Treatment Ulcer
Circulatory Problems Hemophilia Respiratory Disease Venereal Disease
Do you have any disease, condition or problem not listed above that you think I should know about?
       
Medications
allergies
List medications you are currently taking:
Local anesthetics.......................................
Penicillin or other antibiotics.......................
Sulfa drugs................................................
Aspirin........................................................
Codeine or other narcotics ........................
Other:
   
     
AUTHORIZATION AND RELEASE
 
I have read and answered the above questions to the best of my knowledge. I authorize and request my insurance company to pay
directly to the dentist or dental group insurance benefits otherwise payable to me. I authorize the doctor to release all information
necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by
insurance. I authorize the use of this signature on all insurance submissions.
 
Signature of patient or parent if minor: ___________________________________________ Date:
Payment is due in full at time of treatment unless prior arrangements have been approved.

 I certify that I have read and received a copy of this office's Notice of Privacy Practices
     
     
APPOINTMENT POLICY
 

Most people seeking orthodontic treatment have other important obligations during the day, such as work or school.  We value your time both as a parent and patient and make every effort to stay on or ahead of schedule.  We have designed our scheduling system to maximize structure and flexibility.

Many parents work and children attend school. For our school aged patients, it is unavoidable that some school time will be missed.  We try very hard to help you keep this to a minimum.

When active orthodontic treatment begins there are several appointments that can only be done between 8:30 am and 2:00 pm. These appointments are longer appointments and require a lot of doctor time. We try to save our later appointments for those patients just needing their 15 minute monthly adjustments. Each patient is seen about every 3-6 weeks, some of these appointments will inevitably conflict with work or school schedules. We are happy to provide you with a school/work excuse note so you can turn them into your workplace or your child’s school.

Adjustments:  During your treatment, the adjustments are usually completed quickly even though they may be quite technical in nature. These are usually every 3 to 6 weeks.

Comfort Adjustments: These appointments consist of a poking wire or an uncomfortable appliance. Usually a short adjustment will be scheduled as conveniently as possible.

Emergencies:  There are very few “true” emergencies in orthodontics. Patients with severe pain, swelling or bleeding are considered emergencies. These patients will be seen as soon as possible and appropriate care will be given to relieve discomfort. This is usually caused from trauma to the mouth or face. A broken bracket (a braces that comes unglued from the tooth) and missing colored ties are not considered an emergency. Only if there is pain caused from the dislodged bracket, or a sharp poking wire, is it considered an emergency.  If a bracket does come unglued from the tooth, please call our office to schedule a repair appointment

Repairs: These appointments are normally loose bands or brackets, broken wires, lost or broken appliances or retainers. These appointments are longer appointments and are usually scheduled during school hours.

Arriving Late: Because our schedule is carefully crafted, your late arrival can pose a problem. In fairness to the other scheduled patients, we may find it necessary to reschedule your appointment if you are late and we can’t work you in without causing other patients to wait.


I understand and agree to the above policies
Patients Name
Date:
Patient/Guardian/Cardholder’s Signature
 
 
 
         
     
 
       


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