Online Form PATIENT DETAILS Patient's First Name Patient's Last Name Nickname Patient's Address City State State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip GenderGenderFemaleMale Home Phone Date of birth Age RaceRaceAmerican IndianAsianAfrican AmericanHispanic or LatinoPacific IslanderWhiteOther Cell Phone School/Employer Grade/position Work phone How did you hear about our office Email Family members treated in our office Reason for Consultation Previous Dentist Date of last cleaning YesNoIs the patient a minor? If the Guardian & the Patient are the same person, please click here to copy patient information to the next page. RESPONSIBLE PARTY / INSURANCE INFORMATION Self Spouse Father Mother Stepparent Other (specify) Guardian's First Name Guardian's Last Name Home Phone Address City State State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Employer Work Phone Date of birth Social Security Number Cell Phone Guardian's E-Mail INSURANCE (IF APPLICABLE): Company Name Phone Subscriber/Member ID RESPONSIBLE PARTY 2 / INSURANCE INFORMATION YesNo Is there a second guardian and / or additional insurance to add? Self Spouse Father Mother Stepparent Other (specify) Guardian's First Name Guardian's Last Name Home Phone Address City State State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Employer Work Phone Date of birth Social Security Number Cell Phone Guardian's E-Mail OTHER INSURANCE (IF APPLICABLE): Company Name Phone Subscriber/Member ID SLEEP / AIRWAY ISSUES YesNoDoes the patient tend to be a mouthbreather? YesNoDoes the patient snore at night? YesNoDoes the patient seem rested in the morning? YesNoIs the patient often sleepy during the day? YesNoHas the patient seen an Ear, Nose & Throat Specialist? YesNoIs the patient using a sleep apnea device? DENTAL/MEDICAL HISTORY Please check if the patient has a history of the following medical conditions: YesNoAcid Reflux YesNoADHD/ADD YesNoAIDS/HIV YesNoAnemia YesNoArthritis YesNoArtificial Joints YesNoAsthma YesNoAutism YesNoBone Disorders YesNoCancer YesNoCerebral Palsy YesNoChest Pain YesNoChronic Neck Pain YesNoClicking of Jaw YesNoJaw Pain YesNoCold Sores/Herpes YesNoDiabetes YesNoDown Syndrome YesNoEndocrine Problems YesNoEmotional Disorders YesNoEpilepsy YesNoHeadaches YesNoHeart Condition YesNoHepatitis YesNoEar Pain YesNoImmune Problems YesNoKidney Problems YesNoLow Blood Pressure YesNoMuscular Disorders YesNoNervous Disorders YesNoOrgan Transplant YesNoOsteoporosis YesNoPainful Chewing YesNoPeriodontal Problems YesNoProlonged Bleeding YesNoRheumatic Fever YesNoScoliosis YesNoSeizures YesNoSinus Problems YesNoTMJ Problems YesNoTuberculosis YesNoDo your gums bleed when you brush? YesNoIs the patient seeing any other dental specialists? YesNoAny dental restorations needing to be completed? YesNoHave there ever been any injuries to the face, mouth or chin? YesNoHave you ever lost or chipped any teeth? YesNoDo you have any pain or soreness around your face, neck or back? YesNoIs any part of your mouth sensitive to temperature or pressure? YesNoIs the patient currently pregnant? YesNoHave adenoids been removed? YesNoHave tonsils been removed? YesNoCurrently taking any medications? YesNoAre antibiotics necessary prior to treatment? YesNoAllergies? YesNoAny diseases or problems not mentioned above? Please check if the patient has, or ever had, any of the following habits? YesNoCheek, tongue or lip biting YesNoClenching Teeth YesNoFingernail Biting YesNoGrinding Teeth YesNoTongue Sucking YesNoThumb Sucking YesNoTongue Thrusting SIGNED CONSENT I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status. I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate treatment on the above-named patient. I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments. HIPAA Patient Consent I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (a.k.a HIPAA or the Healthcare Privacy Act). I understand that by signing this consent, I authorize This Office to use and/ or disclose my protected healthcare information to carry out the following: Treatment which includes direct and/ or indirect treatment by my other healthcare providers involved in my treatment. Obtaining payment from third party payers, i.e. my dental and/or medical insurance company/companies. The day to day healthcare operations of your dental practice. I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses of disclosures of my protected health information, and my rights under HIPAA. I understand that your reserve the right to change the terms of this notice from time to time and that I may request the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and healthcare operations, but that you are not required to agree to use these requested restrictions. However, if you do not agree, you are bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent will not be affected. Typed Name/Signature Relationship to Patient Date If someone other than the parent(s) or guardian(s) listed above will be bringing the patient to appointments, please list here: By submitting this form you agree to the above mentioned consent statement Submit Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office. Previous Next
