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
YesNo
Home Phone*
Format: (000) 000-0000.
Cell Phone*
Format: (000) 000-0000.
Work phone*
Format: (000) 000-0000.
YesNo
Call Home PhoneText Cell PhoneEmail Message
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
YesNo
If Yes,
YesNo
If Yes,
YesNo
If so, until what age?
YesNo
If so, awake or asleep?
YesNo
YesNo
YesNo
Patient Medical Information
YesNo
If so, why?
YesNo
If so, please list:
YesNo
If so, please list:
YesNo
If yes, what age and doctor?
Present or past medical problem:
Please describe any present or hospitalization and operations:
YesNo
If so, please list date(s) and reason:
YesNo
If so, please list dates/dosage:
YesNo
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?
YesNo
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.*

I do give permission for my photo to be used in any capacity outside of normal orthodontic care.I do NOT give permission for my photo to be used in any capacity outside of normal orthodontic care.
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
Financial InformationOrthodontic Treatment Information
Name
Relationship to Patient
Financial InformationOrthodontic Treatment Information
Name
Relationship to Patient
Financial InformationOrthodontic Treatment Information
Name
Relationship to Patient
Financial InformationOrthodontic Treatment Information
Name
Relationship to Patient
Financial InformationOrthodontic Treatment Information
Signature
Signature (Parent/Guardian, if minor)*

Clear
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