Adult | New Patient Form | Black Orthodontics

Patient Info
Patient Name
Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code

Please provide one phone number for contact purposes.
Home Phone
Cell Phone
Work Phone
Best Number To Contact You?
Birth Date*
MM
DD
YYYY
Email*
Social Security Number
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.
Friend
Relative
Dentist
Dental Hygenist
Other

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 State ZIP Code
Cell Phone
Email
Birth Date*
MM
DD
YYYY
Social Security Number
Relationship to Patient
Employer
Occupation

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

ORTHODONTIC INSURANCE 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
Insuree's Date of Birth
MM
DD
YYYY
Insured's Name
Insured's Social Security Number
Insured's Employer
Insurance Company
Group Number
Local Number
Insurance ID#
Insurance Phone Number

PATIENT'S DENTAL INFORMATION
General Dentist
Dentist Phone Number
Date of Last Visit
MM
DD
YYYY
Please explain in detail specific orthodontic concerns*

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

Adult Patient Form

Step 1 of 11

Patient Info

How did you hear about Black Orthodontics?

RESPONSIBLE PARTY INFORMATION

EMERGENCY CONTACT INFORMATION

ORTHODONTIC INSURANCE INFORMATION

PATIENT'S DENTAL INFORMATION

MEDICAL INFORMATION

PATIENT DENTAL HISTORY

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