1 Step Please Start Here. (Complete all that apply) Patient Name Gender ---MaleFemale Birth Date Age (years & months) Today's Date Street Address City State Zip Code Home Phone # Work Phone # Cell Phone # Email Address Dentist Is patient over 26 years old? YesNo Father's Name D.O.B. Check this box if the contact information is the same as the patient: Street Address City State Zip Code Home # Work # Cell # Mother's Name D.O.B. Check this box if the contact information is the same as the patient: Street Address City State Zip Code Home # Work # Cell # 2 Step Emergency Contact Information Name of an individual you would like to contact in an emergency? Street Address City State Zip Code Home # Cell # Ext # 3 Step Insurance Information Primary Subscriber ID # Dental Insurance Company Phone Street Address City State Zip Code Employer Phone Insured Employee Name D.O.B Date Employed Insured Employee SS# Secondary I do not have secondary insurance Subscriber ID # Dental Insurance Company Phone Street Address City State Zip Code Employer Phone Insured Employee Name D.O.B Date Employed Insured Employee SS# 4 Step Person Financially Responsible for Account Name D.O.B. Address City State Zip Home Phone # Work Phone # Ext # SS # Driver License # Employer Work Address City State Zip 5 Step Please read and answer the following questions 1. Have you been under the care of a medical doctor during the past two years? YesNo Physician's Name Type of Practice Address Phone Last Visited 2. Have you taken any medication or drugs during the past two years? YesNo Are you now taking any medication, drugs, or pills? YesNo If yes, please list: 3. Has the patient ever been hospitalized? YesNo Age of hospitalization: Reason for hospitalization: 4. Has the patient had a history of any of the following? Heart trouble or congenital heart lesions YesNoAsthma, allergies, or sinus infectionsYesNoRheumatic feverYesNoBleeding disordersYesNoNervousness or hyperactivityYesNoHepatitis or liver involvementYesNoEpilepsyYesNoUnfavorable reaction to any medicationYesNo Fainting or dizzinessYesNoDiabetesYesNoTuberculosisYesNoMononucleosisYesNoHearing problems or ringing in the earsYesNoBone, collagen, or hormonal abnormalitiesYesNoGrit or grind teeth (day or night)YesNoHave you seen another orthodontist?YesNo Injuries to face, mouth or teethYesNoMissing or extra permanent teethYesNoClicking, popping or other problem with jawYesNoSpeech problems, speech or tongue therapyYesNoThumb or finger suckingYesNoTonsils and adenoids removedYesNoMouth breathing problemsYesNoOtherYesNo Please describe 5. Family members treated (Past or Current) 6. Height Weight Are you pregnant now? YesNo Have you started menstrual cycle? YesNo 7. Reason for consultation 6 Step Please read Office Policies and Federal Truth-in-Lending statement As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from our patients for the costs incurred in their care to remain viable. Financial responsibility on the part of each patient must be determined before treatment. Patients who carry insurance that covers orthodontic care understand that they are still personally responsible for payments not met by their insurance company. This office will prepare the insurance forms for our patients or assist in making collections from insurance companies and will credit any such collections received to the patient's account. However, this office will not guarantee payment by an insurance company. A service charge of 1.5% (18% per annum) on the unpaid balance will be assessed on all accounts exceeding ninety days from the due dates unless previously written financial arrangements are made. I understand further that the fee estimates given are valid for 12 months following the initial exam. In consideration for the professional services rendered to me, or at my request for my minor child or ward, by the orthodontist, I agree to pay the agreed-upon amount for said services, to said orthodontist. Money owed for services will be billed in a timely manner to patients. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further item or condition, and I further agree to pay all costs and charges billed, payments made, and interest charges assessed, etc. to the orthodontists' collection agency or collection attorney should collection procedures as described become necessary. I grant my permission to you or your assignee to telephone me at home or at my workplace to discuss matters related to this form. I authorize the orthodontist or his designees to release financially identifiable information and treatment descriptions and information, either electronically, by facsimile or paper form to my insurance carrier or any related entities that require such information to be submitted. I certify that I have answered all questions on this form accurately and to the best of my knowledge. I hereby agree to abide by the conditions outlined hereon. I agree to pay the remaining balance plus all collection/court costs and fees if a delinquent balance is placed with a collection agency or attorney. 7 Step Please Sign Below Signature of Patient or Guardian Date Relationship to Patient
