Child Patient Form

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.

Step 1 of 11

Patient Info
Patient Name
Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone
Email*
Birth Date*
Month
Day
Year
Siblings (Names and ages please)

RESPONSIBLE PARTY INFORMATION
Name
Prefix First Last Suffix
Marital Status
Residence
Street Address City State ZIP Code
Mailing Address
Same as previous

Street Address City State ZIP Code

Home Phone
Work Phone
Cell Phone
What is the best contact number?
Email
Birth Date*
Month
Day
Year
Social Security Number
Relationship to Patient
Employer
Occupation

RESPONSIBLE PARTY 2 INFORMATION
Name
Prefix First Last Suffix
Mailing Address
Street Address Address Line 2 City State ZIP Code
Relationship to Patient
Social Security Number
Birth Date
Month
Day
Year
Home Phone
Employer
Occupation

EMERGENCY CONTACT INFORMATION
Contact Name
Phone
Address
Street Address City State ZIP Code
Relationship to Patient

ORTHODONTIC INSURANCE INFORMATION
If the patient is covered under Medicaid please complete all information.
Dental Insurance*
Do you have dental insurance? If so, please select yes, and provide your insurance information.
- Yes
- Yes - will provide at office
- No
Insured's Name
Insured's Mailing Address
Street Address Address Line 2 City State ZIP Code
Insured's Date of Birth
Month
Day
Year
Insured's Social Security Number
Insured's Employer
Insurance Company
Group Number
Local Number
Insurance Company Address
Insurance ID#
Insurance Phone Number

GROWTH AND DEVELOPMENT HISTORY
Has the patient had any recent rapid growth? If yes, what?
Has the patient reached puberty? Females: When? (month & year)
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.
Untitled*
- I am aware a complete notice of Privacy Practices is available upon my request. The Notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, how I may exercise these rights, and the practice's legal duties with respect to my information.
Untitled*
- I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all protected health information residents at, or controlled by, this practice. I understand I can obtain the practice's current Notice of Privacy Practices on request.
Untitled*
- Although exposure is unlikely, I accept the risk and consent to treatment in the Era of COVID-19.
View full Supplemental Informed Consent.
Initials of Patient(if over 18) or Legal Guardian

Contact Us

Phone: 8282777103

E-mail: info@kblacksmiles.com

5 Yorkshire St | Suite A
Asheville, NC 28803

PATIENT INFORMATION
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.
Childs Name	Last *	First *	Middle
Address	Street
Address	City	State	Zip

Phone

Birth date

S.S.N.

E-mail address

School

Grade

How did you hear about Black Orthodontics? (Please supply a name so we can thank them.)
Friend			Website
Relative			Newspaper
Dentist			Yellow Pages
Dental Hygienist			School Partnership Program
Other			ABYSA

Siblings (Names and ages please)

If patient is a minor, give parent’s or guardian’s name.

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 Early Treatment	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.

RESPONSIBLE PARTY INFORMATION
Name			Marital Status
Last *	First *	Middle
Residence	Street
Residence	City	State	Zip
Mailing Address	Street
Mailing Address	City	State	Zip
Home Phone *	Work Phone *	Cell Phone *	E-mail Address *
What is the best contact number?	Birth Date	S.S.N	Relationship to Patient
Employer		Occupation

RESPONSIBLE PARTY 2 INFORMATION
Responsible Party 2 Name
Last	First	Middle	Relationship to Patient
S.S.N	Birth Date	Work Phone
Employer		Occupation

EMERGENCY CONTACT INFORMATION
Contact Name		Phone
Address	Street
Address	City	State	Zip
Relationship to patient

ORTHODONTIC INSURANCE INFORMATION
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

PATIENT’S DENTAL INFORMATION
Child’s Dentist	Date of Last Visit	Dentist Phone Number

MEDICAL INFORMATION & HISTORY
Your Child’s Physician	Phone Number	Date of Last Visit

YES	NO		YES	NO
		Is our child taking any medication? If yes, please specify			Has your child had any major operations?
		Is your child allergic to any medications? If yes, please specify			Has your child ever been involved in a serious accident?
		Does your child have a history of a major illness? If yes, please specify
Has your child 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?

PATIENT DENTAL HISTORY
	YES	NO
Is your child presently in any dental pain?
Has your child ever experienced any unfavorable reaction to dentistry?
Has your child ever lost or chipped any teeth?
Has your child had any injuries to face, mouth or teeth?
Is any part of your child’s mouth sensitive to temperature or pressure?
Do your child’s gums bleed when they brush?
Does your child have any type of thumb or tongue habit?
Is your child a mouth breather?
Has your child ever seen an orthodontist?
Has anyone in the family received orthodontic treatment?
How did they feel about the result?
What is your child’s attitude toward orthodontic treatment?
Does your child’s teeth or jaws ever feel uncomfortable when you awake in the morning?
Is your child aware of their jaw clicking or popping?
Is your child aware of clenching your teeth during the day?
Has your child ever been told that they grind your teeth?
Does your child have “tension” headaches?
Has your child ever experienced chronic ringing in their ears?
Are you aware some appointments will be during school / work hours?

Please list any additional concerns or comments:

GROWTH AND DEVELOPMENT HISTORY
Has the patient had any recent rapid growth? If yes, what?
Has the patient reached puberty? Females: When? (month & year)

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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Child Patient Form

Child Patient Form

Step 1 of 11

Patient Info

How did you hear about Black Orthodontics?

RESPONSIBLE PARTY INFORMATION

RESPONSIBLE PARTY 2 INFORMATION

EMERGENCY CONTACT INFORMATION

ORTHODONTIC INSURANCE INFORMATION

PATIENT'S DENTAL INFORMATION

MEDICAL INFORMATION

PATIENT DENTAL HISTORY

GROWTH AND DEVELOPMENT HISTORY

Contact Us

Child Patient Form