At Black Orthodontics, we want to offer a special plan just for you. Can you help us by answering the following questions? Please answer and check all that apply. |
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Patients Name | Last * |
First * |
Middle |
Address | Street |
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City |
State |
Zip |
Please provide one phone number for contact purposes. * | |||||||||||||||||||||||||||
Home Phone * (xxx) xxx-xxxx |
Cell Phone * (xxx) xxx-xxxx |
Work Phone * (xxx) xxx-xxxx |
Birth Date |
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E-mail Address * |
S.S.N |
Marital Status Married Single Separated Divorced Widowed |
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What is the best number to contact you? |
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Children (Names and ages please) |
What treatment options are you most interested in? | What payment options would be best for you? | ||
Damon Damon Clear Braces Traditional Braces |
Teen Invisalign Invisalign |
Payment in Full with Special Discount No Down Payment Plan – No Interest Affordable Monthly Payments – No Interest Flexible Spending Account |
Chase/Care Credit Extended Payment Plan w/ Interest In-house Financing – No Interest |
Does the patient/responsible party blog? Yes No |
What social Networks are they apart of? Please list them below! ie. Facebook, Twitter etc. |
Check this box if the patient is the Responsible Party. | |||
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Name * (Required fields only if you are the responsible party.) * | Marital Status | ||
Last * |
First * |
Middle |
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Residence | Street |
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City |
State |
Zip |
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Mailing Address | Street |
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City |
State |
Zip |
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Home Phone * |
Work Phone * |
Cell Phone * |
E-mail Address * |
Birth Date |
S.S.N |
Relationship to Patient |
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Employer |
Occupation |
Responsible Party 2 Name | ||
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Last |
First |
Middle |
S.S.N |
Birth Date |
Work Phone |
Employer |
Occupation |
Contact Name |
Phone |
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Address | Street |
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City |
State |
Zip |
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Relationship to patient |
If the patient is covered under Medicaid please complete all information. | ||
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Insured’s Name |
Insured’s S.S.N. |
Insured’s Employer |
Insurance Company |
Group Number |
Local Number |
Insurance Company Address |
Insurance ID # |
Insurance Phone Number |
General Dentist |
Date of Last Visit |
Dentist Phone Number |
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* What concerns you most about your teeth? * |
Please explain in detail specific orthdontic concerns: |
Family Physician |
Phone Number |
Date of Last Visit |
YES | NO | YES | NO | |||
Are you taking any medication? If yes, specify |
Have you had any major operations? | |||||
Are you allergic to any medications? If yes, specify |
Have you ever been involved in a serious accident? | |||||
Do you have a history of a major illness? If yes, specify |
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Have you ever had any of the following diseases or medical problems | ||||||
YES | NO | YES | NO | |||
Abnormal Bleeding / Hemophilia | Hepatitis / Liver Problems | |||||
Anemia | Herpes | |||||
Arthritis | High Blood Pressure | |||||
Asthma or Hayfever | HIV + / AIDS | |||||
Bone Disorders | Kidney Problems | |||||
Congenital Heart Defect | Nervous Disorders | |||||
Diabetes | Pneumonia | |||||
Dizziness | Prolonged Bleeding | |||||
Epilepsy | Radiation / Chemotherapy | |||||
Gastrointestinal Disorders | Rheumatic Fever | |||||
Heart Problems | Tuberculosis | |||||
Heart Murmur | Tumor or Cancer | |||||
Are there any medical conditions we have not discussed that you feel we should be aware of? |
YES | NO | |
Are you presently in any dental pain? | ||
Have you ever experienced any unfavorable reaction to dentistry? | ||
Have you ever lost or chipped any teeth? | ||
Have there been any injuries to face, mouth or teeth? | ||
Is any part of your mouth sensitive to temperature or pressure? | ||
Do your gums bleed when you brush? | ||
Do you have any type of thumb or tongue habit? | ||
Are you a mouth breather? | ||
Have you ever seen an orthodontist? | ||
Has anyone in the family received orthodontic treatment? | ||
How did they feel about the result? | ||
What is your attitude toward orthodontic treatment? | ||
Do your teeth or jaws ever feel uncomfortable when you awake in the morning? | ||
Are you aware of your jaw clicking or popping? | ||
Are you aware of clenching your teeth during the day? | ||
Have you ever been told that you grind your teeth? | ||
Do you have “tension” headaches? | ||
Have you ever experienced chronic ringing in your ears? | ||
Are you aware some appointments will be during school / work hours? | ||
Please list any additional concerns or comments:
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I hereby authorize payment of the group insurance benefits(otherwise payable to me) directly to this office. I understand that I am responsible for all costs for orthodontic treatment whether or not paid by insurance. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered to my insurance company. I authorize the use of this signature on all insurance submissions, whether filed manually or electronically. The information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in my or my child’s medical status. I authorize the dental staff to perform any necessary dental services that I, or my child, may need during diagnosis and treatment, with my informed consent. This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment. I further agree to pay all finance charges, collection costs, attorney’s fees and any other cost that may be incurred to enforce collection of any outstanding balance and authorize credit bureau reports to be obtained for collection purposes. Initials of Patient(if over 18) or Legal Guardian May 16, 2012 |
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