Patient Information Form - Rick Burns Orthodontics

Patient Information
Your Name*
I prefer to be called (Nickname)
Date of Birth*

MonthDayYear
Date
Gender

MaleFemale
Primary Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell/Other Phone
Please enter a valid phone number.
Email Address*
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number (If patient is 18 or older)
School
Hobbies/Sports
If patient is a minor, give parent's or guardian's name
Whom may we thank for referring you to our office?
Other family members seen by us
Responsible Party Information
Parent/Guardian Name
Relationship to Patient
Primary Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Other Phone
Please enter a valid phone number.
Email Address
example@example.com
Residence Address

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth

MonthDayYear
Date
Employer
Occupation
Number of Years Employed
Responsible Party Information
Parent/Guardian Name
Relationship to Patient
Primary Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Other Phone
Please enter a valid phone number.
Email Address
example@example.com
Residence Address

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth

MonthDayYear
Date
Employer
Occupation
Number of Years Employed
Patient's Dental History
General Dentist
Dentist's Phone
Please enter a valid phone number.
Date of Last Visit

MonthDayYear
Date
What would you like orthodontics to accomplish?
Does the patient brush their teeth daily?

YesNo
Does the patient floss his/her teeth daily?

YesNo
Has the patient been evaluated or had orthodontic treatment before?

YesNo
When?

MonthDayYear
Date
Has the patient had any injuries to the face, mouth, teeth or chin?

YesNo
Has the patient been informed that he/she has any missing or extra permanent teeth?

YesNo
Has the patient had any pain/tenderness in his/her jaw joint (TMJ/TMD)?

YesNo
Has the patient's adenoids and/or tonsils been removed?

YesNo
Has the patient experienced any of the following?
Clenching and/or grinding teeth

YesNo
Lip sucking and/or biting

YesNo
Mouth breathing

YesNo
Nail biting

YesNo
Nursing/bottle habits

YesNo
Speech problems

YesNo
Thumb and/or finger sucking

YesNo
Tongue thrusting

YesNo
Patient's Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.
Primary Care Physician
Phone
Please enter a valid phone number.
Date of Last Visit

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Please check any of the following which apply to you, and add any relevant comments.*

	Check	Comment
Are you taking any medication?
Are you allergic to any medication?
Do you have a history of any major illness?
Have you had any major operations?
Have you ever been involved in a serious accident?

Please check any of the following that you have had or currently have:

Abnormal bleeding/HemophiliaADHD/ADDArthritisArtificial Bones/JointsAsthma or Hay feverCongenital Heart DefectDiabetesEmphysemaEpilepsyGlaucomaHandicaps/DisabilitiesHearing ImpairmentsHeart AttackHeart MurmurHepatitis/Liver ProblemsHerpesHigh Blood PressureHIV/AidsLupusRadiation/ChemotherapyRheumatic/Scarlet FeverSeizuresStrokeThyroid ProblemsTuberculosisTumor or Cancer
Are there any medical conditions we have not discussed that you feel we should be aware of?
Latex Allergy?

YesNo
Metal/Nickel Allergy?

YesNo
Plastic Allergy?

YesNo
Consent for Treatment/Financial Responsibility
THE PARENT OR GUARDIAN WHO INITIATES TREATMENT IS FINANCIALLY RESPONSIBLE. Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest confidence, and it is my responsibility to inform this office of any changes in my child's medical status.
If this office accepts insurance, I UNDERSTAND THAT I AM RESPONSIBLE FOR PAYMENT OF SERVICES RENDERED AND RESPONSIBLE FOR PAYING ANY AMOUNT INCLUDING CO-PAYMENT AND DEDUCTIBLES THAT MY INSURANCE DOES NOT COVER. I hereby authorize payment of group insurance benefits directly to this office.

I authorize the dental staff to perform the necessary dental/orthodontic services that my child may need during diagnosis and treatment.
Electrontic Signature*

Clear
HIPAA Consent
Please list anyone that you request be allowed for the disclosure of your Protected Health Information. Protected Health Information would include your name, diagnosis(es), test results, treatment plan and dates of service.

For patients under the age of 18, this would include anyone other than their biological parent(s) and/or legal guardian(s) - such as grandparents, siblings, etc.
Please check all that apply

You may disclose Protected Health Information to my family members (other than legal guardians) and/or non-family members. Please list their name, phone number, and relationship to the patient.You may leave Protected Health Information on my answering machine/voicemail.
Name - Phone Number - Relationship
Phone Number
Please enter a valid phone number.
Electronic Signature*

Clear
If you wish not to disclose information, you may choose not to list anyone. However we will still need an electronic signature for acknowledgement.
Primary Dental Insurance Information
Insurance Company
Insurance Company's Phone Number
Please enter a valid phone number.
Insurance Company's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Member ID
Policy Owner's Employer
Policy Owner's Name
Policy Owner's Social Security Number
Policy Owner's Phone Number
Please enter a valid phone number.
Policy Owner's Date of Birth

MonthDayYear
Date
Policy Owner's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Patient
Secondary Dental Insurance Information
Insurance Company
Insurance Company's Phone Number
Please enter a valid phone number.
Insurance Company's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Member ID
Policy Owner's Employer
Policy Owner's Name
Policy Owner's Social Security Number
Policy Owner's Phone Number
Please enter a valid phone number.
Policy Owner's Date of Birth

MonthDayYear
Date
Policy Owner's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Patient
By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
Should be Empty:

Patient Information

Responsible Party Information

Responsible Party Information

Patient's Dental History

Patient's Medical History

Consent for Treatment/Financial Responsibility

HIPAA Consent

Primary Dental Insurance Information

Secondary Dental Insurance Information