Patient Information - Dietrich Orthodontics

Health History
Patient’s Name

Patient's First NamePatient's Last Name
Preferred Phone
Format: (000) 000-0000.
Patient DOB

MonthDayYear
Date
School
Grade
Height
Weight
Have you been out of the country in last 2 years & where?
Patient Physician
Patient General Dentist
Responsible Party Information

(Person responsible for paying the account)
Name
Responsible Party Email
example@example.com
Residence

Street Address

Street Address Line 2

CityState

Zip Code
I agree that the practice may communicate with me electronically at the email address above. I am aware that there is some level of risk that third parties may be able to read unencrypted emails. I am responsible for providing any updates to my email address. I may withdraw my consent at any time.
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Work phone
Format: (000) 000-0000.
I agree that the practice may communicate with me via text at the cell number(s) above. I am aware that there is some level of risk that third parties may be able to read unencrypted texts. I am responsible for providing any updates to my cell number. I may withdraw my consent at any time.
Preferred appointment reminders (check all that apply)?
Previous Address (if less than 3 years)

Street Address

Street Address Line 2

CityState

Zip Code
Marital Status
Social Security #
Birth Date

MonthDayYear
Date
Relationship to Patient
Employer
Occupation
No. years employed
Spouse’s Name
Spouse's Relationship to Patient
Spouse’s Employer
Spouse’s Occupation
No. years employed
Spouse’s Social Security #
Spouse’s Birth Date

MonthDayYear
Date
Patient Dental Information
Date of last dental check-up

MonthDayYear
Date
Any facial or Dental injuries?
If Yes,
Any teeth removed by your dentist?
If Yes,
Any thumb or finger sucking habit?
If so, until what age?
Any difficulty breathing through the nose (awake or asleep)
If so, awake or asleep?
Any tooth clenching and/or grinding?
Any Speech problems?
Any clicking or pain when opening or closing the mouth?
Patient Medical Information
Is the patient currently under the care of a physician?
If so, why?
Is patient taking any medication now?
If so, please list:
Any allergies or drug sensitivity?
If so, please list:
Have tonsils and/or adenoids been removed?
If yes, what age and doctor?
Present or past medical problem:
Please describe any present or hospitalization and operations:
Has the patient had blood transfusions?
If so, please list date(s) and reason:
Have you ever taken Bisphosphonates?
If so, please list dates/dosage:
Do you smoke or use tobacco?
If so, for how long?
Patient General Information
What concerns you most about the patient’s teeth and facial appearance?
Have other family members had orthodontic treatment?
Does anyone in your family have a similar dental problem?
Do you have siblings?
If so, please list names and dates of birth:
Emergency Contact
Preferred Emergency Contact Person
Complete Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone
Format: (000) 000-0000.
Relationship to Patient
Photo Permission
We offer many different contests and educational programs, along with before/after treatment photos that would allow you or your child to be a part of our social media, website, educational materials, and office postings. For your privacy, we do not include any last names on these photos and/or announcements. By signing below, I’m authorizing the practice to use the patient’s photo on all social media accounts, the website, and in the office. I hereby relinquish any and all rights to photographs, portraits, transparencies, negatives, prints, Polaroids, or other photographic reproductions captures with still, motion picture, video or other cameras for use by Joseph S Dietrich DMD LLC / DBA Dietrich Orthodontics.
Name of nearest relative
Notice of Privacy Practices Acknowledgement

* You May Refuse to Sign This Acknowledgment*
HIPAA Access
Due to the HIPAA Privacy Rule, we must have permission for any other person to have access to the account/healthcare records.

Please list below the names of the people who are allowed access to the above named account, including yourself, biological parents, step-parents, grandparents, if applicable.
Name
Relationship to Patient
Allowed Access To:
Name
Relationship to Patient
Allowed Access To:
Name
Relationship to Patient
Allowed Access To:
Name
Relationship to Patient
Allowed Access To:
Name
Relationship to Patient
Allowed Access To:
Signature
Signature (Parent/Guardian, if minor)
Date

MonthDayYear
Date
Should be Empty:

Health History

Responsible Party Information

Patient Dental Information

Patient Medical Information

Patient General Information

Emergency Contact

Photo Permission

Notice of Privacy Practices Acknowledgement

HIPAA Access

Signature