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.
Patients Name Last *
First *
Middle
Address Street
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
E-mail Address *
S.S.N
Marital Status
Married    Single    Separated Divorced    Widowed
What is the best number to contact you? 
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
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.

 

RESPONSIBLE PARTY INFORMATION
 Check this box if the patient is the Responsible Party.
Name * (Required fields only if you are the responsible party.) * Marital Status
Last *
First *
Middle
Residence Street
City
State
Zip
Mailing Address Street
City
State
Zip
Home Phone *
Work Phone *
Cell Phone *
E-mail Address *
Birth Date
S.S.N
Relationship to Patient
Employer
Occupation

 

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

 

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

 

ORTHODONTIC INSURANCE INFORMATION
If the patient is covered under Medicaid please complete all 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
General Dentist
Date of Last Visit
Dentist Phone Number
* What concerns you most about your teeth? *
Please explain in detail specific orthdontic concerns:

 

MEDICAL HISTORY
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
     
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?

 


PATIENT DENTAL HISTORY
  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:

 


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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