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
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
City
State
Zip
Mailing Address Street
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
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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