Adult 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 9% Patient InfoPatient NameName* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please provide one phone number for contact purposes.Home PhoneCell PhoneWork PhoneBest Number To Contact You?Birth Date* MM DD YYYY Email* Children (Names & Ages, please) How did you hear about Black Orthodontics? School Partnership Program ABYSA Online Social Media Through a Friend Please supply a name so we can thank them.FriendRelativeDentistDental HygenistOther What treatment options are you most interested in? Metal Braces Clear Braces Retainer Invisalign What payment options would be best for you? Payment in Full with Special Discount No Down Payment Affordable Monthly Payments - No Interest Flexible Spending Account Chase/Care Credit RESPONSIBLE PARTY INFORMATION Check this box if the patient is the Responsible Party. Name First Last Residence Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell PhoneEmail Birth Date* MM DD YYYY Social Security NumberRelationship to PatientEmployerOccupation EMERGENCY CONTACT INFORMATION Contact Name Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneRelationship to Patient ORTHODONTIC INSURANCE INFORMATION Dental Insurance:*Do you have dental insurance? If so, please select yes, and provide your insurance information.YesYes - will provide at officeNoInsuree's Date of Birth MM DD YYYY Insured's NameInsured's Social Security NumberInsured's EmployerInsurance CompanyGroup NumberLocal NumberInsurance ID#Insurance Phone Number PATIENT'S DENTAL INFORMATION General DentistDentist Phone NumberDate of Last Visit MM DD YYYY Please explain in detail specific orthodontic concerns* MEDICAL INFORMATION Family PhysicianDate of last visit MM DD YYYY Are you taking any medications?YesNoIf yes, specifyAre you allergic to any medications?YesNoIf yes, specifyDo you have a history of a major illness?YesNoIf yes, specifyHave you had any major operations?YesNoHave you ever been involved in a serious accident?YesNoHave you ever had any of the following diseases or medical problems?Abnormal Bleeding / HemophiliaYesNoAnemiaYesNoArthritisYesNoAsthma/ HayfeverYesNoBone DisordersYesNoCongenital Heart DefectYesNoDiabetesYesNoDizzinessYesNoEpilepsyYesNoGastrointestinal DisordersYesNoHeart ProblemsYesNoHeart MurmurYesNoHepatitis/ Liver ProblemsYesNoHerpesYesNoHigh Blood PressureYesNoHIV + / AIDSYesNoKidney ProblemsYesNoNervous DisordersYesNoPneumoniaYesNoProlonged BleedingYesNoRadiation/ ChemotherapyYesNoRheumatic FeverYesNoTuberculosisYesNoTumor or CancerYesNoAre there any medical conditions we have not discussed that you feel we should be aware of? PATIENT DENTAL HISTORY Are you presently in any dental pain?YesNoHave you ever experienced any unfavorable reaction to dentistry?YesNoHave you ever lost or chipped any teeth?YesNoHave there been any injuries to face, mouth or teeth?YesNoIs any part of your mouth sensitive to temperature or pressure?YesNoDo your gums bleed when you brush?YesNoAre you a mouth breather?YesNoHave you ever seen an orthodontist?YesNoHas anyone in the family received orthodontic treatment?YesNoHow did they feel about the result?What is your attitude toward orthodontic treatment?Are you aware of your jaw clicking or popping?YesNoDo your teeth or jaws ever feel uncomfortable when you wake in the morning?YesNoAre you aware of clenching your teeth during the day?YesNoHave you ever been told that you grind your teeth?YesNoDo you have "tension" headaches?YesNoHave you ever experienced chronic ringing in your ears?YesNoAre you aware some appointments will be during school/work hours?YesNoPlease list any additional concerns or comments: 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.* 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. * 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. * 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*Date* MM DD YYYY Contact Us Phone: 8282777103 E-mail: [email protected] 5 Yorkshire St | Suite AAsheville, NC 28803 Name Email Address Message Submit