Step 1 of 5 20% Patient's First Name* Patient's Middle Name Patient's Last Name* Nickname SS#* Patient's Address* City* State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip* Gender*GenderMaleFemaleDate of birth* MM slash DD slash YYYY Home Phone*Work phone*School/Employer* Grade/position* How did you hear about our office* Email* Family members treated in our office* Reason for Consultation* Previous Dentist* Date of last cleaning* MM slash DD slash YYYY Is the patient a minor?* Yes No RESPONSIBLE PARTY / INSURANCE INFORMATIONOptions* Self Spouse Father Mother Mother Other Guardian's First Name* Guardian's Last Name* Date of birth* MM slash DD slash YYYY Home Phone*Cell Phone*Address* City* State*StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificEmployer* Work Phone*Guardian's E-Mail* INSURANCE (IF APPLICABLE): Company Name* Phone*Subscriber/Member ID SLEEP / AIRWAY ISSUESDoes the patient tend to be a mouthbreather? Yes No Does the patient snore at night? Yes No Does the patient seem rested in the morning? Yes No Is the patient often sleepy during the day? Yes No Has the patient seen an Ear, Nose & Throat Specialist? Yes No Is the patient using a sleep apnea device? Yes No DENTAL/MEDICAL HISTORYPlease check if the patient has a history of the following medical conditions: AIDS Alzheimer's/Dementia Anemia Arthritis, Rheumatism Artificial Heart Valves Artificial Joints Asthma Back Problems Blood Disease Cancer Chemical Dependency Chemotherapy Circulatory Problems Cortisone Treatments Coughing, Persistent Cough up Blood Diabetes Epilepsy Fainting Glaucoma Headaches Heart Murmer Heart Problems Other Hemophilia Hepatitis High Blood Pressure HIV Positive Jaw Pain Kidney Disease Liver Disease Low Blood Pressure Mitral Valve Prolapse Nervous Disorders Pacemaker Psychiatric Care Radiation Treatment Respitory Disease Rheumatic Fever Scarlet Fever Shortness of Breath Sinus Infection Skin Rash Stroke Swelling of Feet or Ankles Thyroid Problems Tobacco Habit Tonsillitis Tuberculosis Ulcer Venereal Disease Vitamin B12 Deficiency Have you ever been treated for osteopporosis? Yes No Are you or have you ever taken Bisphosphonates such as: Fosamax, Actonel, Boniva, Zometa or Aredia? Yes No Have you ever taken Redux or Fen-Phen Yes No Do your gums bleed when you brush? Yes No Is the patient seeing any other dental specialists? Yes No Any dental restorations needing to be completed? Yes No Have there ever been any injuries to the face, mouth or chin? Yes No Have you ever lost or chipped any teeth? Yes No Do you have any pain or soreness around your face, neck or back? Yes No Is any part of your mouth sensitive to temperature or pressure? Yes No Is the patient currently pregnant? Yes No Have adenoids been removed? Yes No Have tonsils been removed? Yes No Currently taking any medications? Yes No Are antibiotics necessary prior to treatment? Yes No Allergies? Yes No Any diseases or problems not mentioned above? Yes No Please check if the patient has, or ever had, any of the following habits?* Cheek, tongue or lip biting Clenching/Grinding Teeth Fingernail Biting Thumb Sucking 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* MM slash DD slash YYYY 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
