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* Month Day Year 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.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 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* Month Day Year Social Security Number Relationship to Patient Employer Occupation 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. Yes Yes - will provide at office No Insuree's Date of Birth Month Day Year Insured's Name Insured's Social Security Number Insured's Employer Insurance Company Group Number Local NumberInsurance ID# Insurance Phone Number PATIENT'S DENTAL INFORMATION General Dentist Dentist Phone NumberDate of Last Visit Month Day Year Please explain in detail specific orthodontic concerns* MEDICAL INFORMATION Family Physician Date of last visit Month Day Year Are you taking any medications? Yes No If yes, specify Are you allergic to any medications? Yes No If yes, specify Do you have a history of a major illness? Yes No If yes, specify Have you had any major operations? Yes No Have you ever been involved in a serious accident? Yes No Have you ever had any of the following diseases or medical problems?Abnormal Bleeding / Hemophilia Yes No Anemia Yes No Arthritis Yes No Asthma/ Hayfever Yes No Bone Disorders Yes No Congenital Heart Defect Yes No Diabetes Yes No Dizziness Yes No Epilepsy Yes No Gastrointestinal Disorders Yes No Heart Problems Yes No Heart Murmur Yes No Hepatitis/ Liver Problems Yes No Herpes Yes No High Blood Pressure Yes No HIV + / AIDS Yes No Kidney Problems Yes No Nervous Disorders Yes No Pneumonia Yes No Prolonged Bleeding Yes No Radiation/ Chemotherapy Yes No Rheumatic Fever Yes No Tuberculosis Yes No Tumor or Cancer Yes No Are 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? Yes No Have you ever experienced any unfavorable reaction to dentistry? Yes No Have you ever lost or chipped any teeth? Yes No Have there been any injuries to face, mouth or teeth? Yes No Is any part of your mouth sensitive to temperature or pressure? Yes No Do your gums bleed when you brush? Yes No Are you a mouth breather? Yes No Have you ever seen an orthodontist? Yes No Has anyone in the family received orthodontic treatment? Yes No How did they feel about the result? What is your attitude toward orthodontic treatment? Are you aware of your jaw clicking or popping? Yes No Do your teeth or jaws ever feel uncomfortable when you wake in the morning? Yes No Are you aware of clenching your teeth during the day? Yes No Have you ever been told that you grind your teeth? Yes No Do you have "tension" headaches? Yes No Have you ever experienced chronic ringing in your ears? Yes No Are you aware some appointments will be during school/work hours? Yes No Please 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* Month Day Year Δ Contact Us Phone: 8282777103 E-mail: info@kblacksmiles.com 5 Yorkshire St | Suite AAsheville, NC 28803 Name Email Address Message Submit
