Adult New Patient Form

Patient Information

Patient's First Name

Patient's Middle Initial

Patient's Last Name

Patient's Nickname

What pronouns would you like us to use?

Patient's Date of Birth

Patient's Gender

Social Security Number

Address

City

State

ZIPCode

Phone

Accept Text Messages? Yes No

Marital status?

Employer

Occupation

Work Phone

Employer Address

Patient's Dentist

Who is financially responsible for this account?

Spouse Information

First Name

Last Name

Relationship to Patient

Marital status?

Social Security Number

Date of Birth

Gender

Address

City

State

ZIPCode

Phone

Accept Text Messages? Yes No

Employer

Occupation

Work Phone

Employer Address

Primary Dental Insurance Company

Do you have dental insurance? Yes No

Secondary Dental Insurance Company

Do you have secondary dental insurance? Yes No

Medical History Information Primary concern with teeth?

Has the patient been under the care of a physician during the past two years? Yes No

Is the patient taking any medication or drugs? Does the patient have a history of major illness or hospital stay? Please elaborate on the above or describe other medical concerns: Special Needs

Have tonsils and adenoids been removed? Yes No

At what age were they removed?

Has the patient ever sucked a thumb or fingers? Yes No

Until what AGE?

Has the patient or other family members had any previous orthodontic treatment? Yes No

Has the patient been informed of any missing or extra permanent teeth? Yes No

Does the patient have any jaw pain or noise in the jaw joint? Yes No

Does the patient play a musical instrument (mouth only)? Yes No

How many hours per day?

Have there been injuries to the face, mouth or teeth? Yes No

Other Information How did you hear about us, or were you referred by someone?

Notice of Privacy Practices Acknowledgment (HIPAA) View/print the Notice of Privacy Practices (HIPAA)

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.

Obtain payment from third-party payers.

Conduct normal healthcare operations such as quality assessments and physician certifications.

I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization, at the address listed above, to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Signature

My submission of this file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

I understand that entering my name below is the same as signing and that my physical signature will be required to confirm the acknowledgments above at the time of my office visit.

Your First Name

Your Last Name

Date